A "HealthTweep" Pulse Check

On Tuesday, December 8th, 2009 I had the please of speaking with Bryan Vartebedian, MD, a pediatric gastroenterologist, active in the social media space via Twitter @Doctor_V, his personal blog 33Charts.com, and periodic contributor to Get Better Health.

We spoke via Blog Talk Radio on his calling to medicine, pediatrics in particular and more recently his attraction to the social media space. Doctor_V has both interesting and witty insights on the medium. Some of his more recent tweets are noteworthy:

When I mention SM to other physicians they just giggle and look confused

LinkedIn may be a good first step for socially retarded physicians

Social media is the fancy awning that hangs from a building; human interaction is the bricks & mortar (a re-tweet)

For more of ‘Doctor_V’s insight, wit and early ‘do’s and don’ts’ for physicians considering a social media presence, listen in to the full interview here.

OK Tweeps in the movie ‘What the Bleep‘ do we know, the line transitioning to the theme of the flick proffers:

it’s time to get wise.

Well the same holds true with respect to the ‘resistance is futile’ health care borg aka ‘the tapeworm medical industrial complex’ economy. Our health care system is at risk of collapse; with 46 million uninsured, 25 million under-insured, primary care physicians bailing on the system daily, health care premiums sky rocketing, while benefits are being reduced and cost shifted from the plan to the employee. No one is happy with this status quo, quite to the contrary of some public opinion polls that tout we have the ‘best health care system’ in the world!

Surely we have the best high tech or ‘rescue care’ medicine that can be found. But when it comes to the ‘value proposition’ the story gets a little more complicated, and requires a bit more than sound-bytes or political grandstanding to get at the truth.

Money Driven Medicine is a primer for such a rational conversation. If we thought the Senate Finance Committee hearings followed by the debate of Chairman’s mark was exhausting, just wait for what’s in store from the special interests, and their ‘Quack-er’ proxies in the Senate during the impending floor debate of the merged bills.

So why not get current and be a part of the solution? Watch Money Driven Medicine and get WISE!

While the political theater slogs towards it’s ‘battle fatigue’ finale in Washington, D.C., and elswhere in the United States of Amnesia, one American, who also happens to be a politician has decided to approach our health care conundrum in the spirit of the Cluetrain Manifesto and from the footprint of the human experience via a story telling process, i.e., the human narrative.

The name is Congressman Alan Grayson, and the site is Names of the Dead (dot) com. While some will immediately look to party affiliation, and standing with respect to the health reform bills before the Congress to position how they’ll ‘receive’ (or discount via an ideological filter) his message, I encourage you to watch some if not all of the videos.

They are personal stories of Americans who died directly as a result of delayed access to medical care. An empirical basis for the claim that lack of health insurance is associated with mortality is provided in the peer reviewed study Health Insurance and Mortality in US Adults.

The publishing of this report is a timely and top of mind topic, since as a male I am one of the 47 million Americans without health insurance, and a boomer in his 50s, who has occasion to think about the 1 in 6 prospects of prostate cancer in my future. Specifically I have pondered, and have avoided to date, submitting to a PSA test. And yesterday via virtual participation in the TEDMED hashtag stream (#tedmed) I came across a prostate CA piece from theVisualMD dot com, which only further affirmed my fear, and stoked a somewhat borderline despair.

Why ‘borderline’ despair? A few illogical and perhaps ‘magical thinking’ reasons come to mind:

• I am avoiding the test since ‘ignorance is bliss, and I am uninsured?’ Ergo, if I or any lab for that matter doesn’t know, then it can’t be confirmed as a pre-existing condition, right?; and
• If I am a positive, then what? I am not insured and can’t afford the treatment. So county here I come? No thanks, I don’t subscribe to the ‘John Goodman theory’ about the mythology of the uninsured in America.

So my choices are to sit with the 1 in 6 odds and continue as I am, pretending not to be concerned. After all, my history is disease free, and as a health care ‘insider’ I avoid interacting with the health care delivery system as a general rule, staying active and eating healthy for the most part.

Yet, I can’t help but think about those stories that Grayson is sharing with America and asking myself, will I be on the list soon?

So while we debate and more accurately obfuscate the nature of the problem we face vis a vis health reform solutions, people die daily. The ‘dead man walking’ queue witnesses some 122 new recruits each and every day.

The health reform imperative is real tweeps. Unfortunately the dividing line all to often seems to be between those who are employed, and have health insurance (aka, the I got mine crowd) and those who do not; many of whom are employed or self employed but none-the-less locked out of the system due to obscene health care costs or opportunistic underwriting and/or retrospective rescission schemes.

So what’s it going to be peeps? As a society, who will we value and install as the ‘anchor’ tenant in medicine? Will it be (generically speaking) a Mayo model, or the status quo, volume incented, quantity driven series of competitive fee-for-service sweat shops, dba ‘McAllen’s’ (generically speaking of course)?

And boldly ask:

Is the end of aging in sight?

The TEDMED conference agenda is jam packed with innovators in technology, education and design all focusing their considerable energies on the applications of genomics to real world problems in medicine including the ‘holy grail’ of extending human life, and reinventing the management, if not elimination, of disease.

TEDMED is an extension of the TED (Technology, Education & Design) Series founded by Richard Saul Wurman. Marc Hodosh is President of TEDMED, a conference he is re-launching right here in San Diego.

Previously Marc led the Archon X PRIZE for Genomics, a $10 million competition to inspire rapid and cost effective genome sequencing technology; which followed the highly successful $10 million Ansari Space X PRIZE.

With the publication of his first book in 1962 at the age of 26, Richard Saul Wurman, began the singular passion of his life: making information understandable. He chaired the International Design in Aspen in 1972, the first Federal Design Assembly in 1973, followed by the National AIA Convention in 1976, before creating and chairing TED conferences from 1984-2002.

Wurman created and chaired the TEDMED and eg2006 conferences. A B.A. and M.A. 1959 graduate with highest honors from the University of Pennsylvania, Mr. Wurman’s nearly half-century of achievements includes the publication of his best-selling book Information Anxiety and his award winning ACCESS Travel Guides.

To contextualize and perhaps frame the conference mindset, a key equation for ‘good health’ was outlined by Bill Davenhall, of ESRI, as follows:

Genetics + lifestyle + environment = risks

According to Alana B. Elias Kornfeld, of the HuffingtonPost: ‘Davenhall spoke about the missing piece to understanding personal health: the environment.’

For a summary of Day One at TEDMED 2009, see Kornfeld’s article TED MED 2009: The Missing Piece In Understanding Our Health.

Note: For the less fortunuate of us unable to attend this conference, you may follow the tweets, aka ‘digital footprint’ via many health tweeps participating in the event using the Twitter hashtag of #TEDMED.

Have you ever been sucked into the white waters of the Pacific after falling off your board; only to find yourself gasping for air yet unable to surface? It’s kinda frightening, even for the more accomplished surfers’ amoung us.

Ok you say, I got the visual, but don’t surf and what’s that got to do with health reform? It’s really quite simple. The oxygen (or change imperative ‘momo’) is gone, and the business owner of the reform narrative is desparately flailing for air. What was once seeminbgly brilliant political positioning, i.e., ‘you (the Congress) give me something I can sign into law, now appears to have degraded into a desparate ‘chicken dance’ in search of a tangible face saving political accommodation.

Yet, the war is over and the health insurance industry has already won. They’ve successfully enrolled us in their ‘faux hope’, yet compelling version of ‘The Matrix’. Never mind the 46 million uninsured, or the expanding ranks of the ‘diminishing returns’ under-insured, the dubious and seedy practices of cherry picking or worse yet retrospective recissions, while the relentless and intractable ‘evolution’ of the health insurance industry away from comprehensive (true HMO like) coverage to smartly branded (Edward Bernays could not have offered better ‘reframing’ counsel) ‘consumer directed health plans’, essentially re-defines the industry.

Why United, Aetna, WellPoint, the Blues, or their regional derivative iterations et al, so wholeheartedly embracing this dressed up risk shifting charade is not prima facia evidence that they can’t cut it, have patently failed the American public, and despite their scale, can not manage health risk let alone delivery systems is not front and center in the health reform conversation is beyond me. Where is the primacy of the ‘Mayo (collectively speaking of organically baked, physician group culture based integrated delivery systems) v. McAllen” (as proxy for fee for service sweat shops) debate?

To my great dismay, this tektonic healthplan (health insurance) risk shift is in some measure aided and abetted by well meaning, thoughtful and committed ‘health 2.0 entrepreneuers’ who passionately pursue web based technologies with intent to empower consumers in the crosshairs and rapicious appetite of the ‘resistence is futile’ health care borg.

In the end (and yes, it is over, for now…) that which plays out in Congress will be pure facing saving attempts to ‘put lipstick on a pig with whack a mole DNA’. The byproduct and amalgamation of this output alchemized by the forces of unreasonable change, leveraged by the vocal naysayers relentlessly pursuing their culture war agenda to pierce the veil of what seemed to be a Presidential mandate above reproach, will castrate once hopeful visions of the health reform we so desparately need.

In view of this dumbed down pseudo national conversation, I imagine more slack will be cut for the failed architects of the ‘HillaryCare’ initiative. Apparently, the Millenial answer was not to stay above the fray via Obama’s ‘Eight Principles of Health Reform‘, but perhaps pursue a more managed center absent artificial legistlative deadlines, coupled with enlightened curators of the conversation.

So what’s a ‘preferred hospital’ anyway?  A fair question, since ‘beauty’ is for the most part in the mind of the beholder!

Preferred Hospitals remains a conceptual ‘on the come’ value proposition at this point; but when I first thought of the idea, I had in mind structuring a network of participating hospitals and physicians directed primarily to the 47 million Americans without health insurance. The network’s ’secret sauce’ consisted of providers who contractually committed to a substantially discounted (equivalent to the best or “most favored nation’s”) rates, otherwise extended to ‘wholesale buyers’, i.e., health plans, with the greatest group purchasing leverage.

In the economics of managed care, the more members a health plan trafficked in a specific market, the greater provider discounts they could expect. Most favored nations rates often equated to 50 cents on the dollar (or less!) , i.e., a 50% discount. Thus, the value proposition (to the uninsured) was twofold: (1) the contract rates would be actually honored, and therefore the member would receive a benefit in exchange for the modest dues paid vs. told ‘we don’t participate with that plan’; and (2) the provider’s rates would be adjusted to ‘fair value’ at least as determined by the entities with the greatest purchasing power in that market.

The great irony is hospitals and physicians too often (whether by design or not) reserve their ‘retail book’, i.e., billed charges, for the least able to bear the burden of charge based ’sticker shock’. Many offer cash discounts as a courtesy in the +/- 25% range, but too often fail to present that option upfront before the downstream litany of collection calls.

At the time I originally entertained the idea, the discounted medical plan marketplace (DMPO) was populated with flimsy players, many of whom where exposed by the Georgetown University Study ‘Discount Medical Cards: Innovation or Illusion?‘ So it appeared this idea would have traction in the marketplace. While I enthusiastically jumped in, I found myself banging my head on the wall, over and over again. The value proposition seemed so apparent to me; especially linking the emerging growth of retainer, concierge or micropractices to a targeted and under-served market that contrary to popular wisdom was not a indigent demographic per se. Further, I reasoned (incorrectly I might add) that many of the forward thinking, and compassionate hospital systems (especially the one I worked for in DFW), forged under benefit of tax exemptions would proactively embrace a solution designed to reach an underserved market, and thus make a material deposit into the ‘community benefit’ bank. With IRS and the Congress on the non-profit hospital trail (i.e., Chuck Grassley, et al) looking into the veracity of 990 filiings, certainly these hospitals would see the light and embrace the greater good this model so obviously afforded; not!

None-the-less, I began to negotiate ‘upstream’ with several national PPO network managers, who in search of incremental revenues, and fighting ’silent PPO allegations’, were electing to ‘rent’ and private label their networks in exchange for a per member, per month (PMPM) fee that ranged at that time between $3.50 – $4.00. Yet, as a start up with no membership, it became solely a cat and mouse affair. The PMPM basis was a function of the membership base which at that time was zero. From their perspective, it was a pure play ‘on the come’ business model, and good intentions not withstanding, we could not come to terms.

I also approached several colleagues, and friends in the personalized, retainer model, or concierge medicine market, and attempted to interest them in the business model. Most notably the Society for Innovative Medical Practice Design (SIMPD) was a logical partner or sponsor (I reasoned) to which I ‘pitched’ the idea, though to no avail. They were just not interested in ‘marketing” their nascent member panel at the time, nor reaching out to this underserved market per se.

Thus, no traction developed, and after much time soliticing support, and partner participation, I elected to back off of the business model.

So fast forward a few years and witness the ‘health reform 2.0 moment’ we’re all having. Revived thoughts have surfaced as to what and how a preferred hospitals network might be structured?

Here are a few ‘indicia’ of an emerging preferred hospitals manifesto:

• Commit to pricing, cost and quality transparency
• Adopt social media guidelines to engage and empower patient utilization of the hospital’s services (pre-admission, during and post discharge; especially follow-up concerns)
• Offer ‘members’ most favored nations’ rates via a credible discount medical plan(s)
• Waive where possible, or otherwise, defer collection of all upfront fees, copays, estimated co-insurance, and/or deductibles
• Participate in budget driven and consumer specific time payment programs (as determined by independent financial counselors) via auto-debit direct from the patient’s bank (interest free)

This is only a start. I welcome your thoughts.

On the ‘hopium’ of health reform, where do you stand?

“I don’t believe there’s any problem in this country, no matter how tough it is, that Americans when they roll up their sleeves, can’t completely ignore.” ~ George Carlin

“Better brace yourselves for a whole lotta ugly comin’ at you, from a never ending parade of stupid!” ~ Queen Latifah

“Somebody has to do something, and it’s just incredibly pathetic that it has to be us.” ~ The ‘late’ Jerry Garcia (of Deadhead fame)

On July 30 through August 1st the Colorado Health Foundation (CHF)  held a superb conference titled ‘The New  Health Policy Landscape‘. While regrettably I was not able to attend, I followed the ‘tweets’ of @HealthSymposium, and health tweeps using the #09chs hashtag feed. According to their website the conference was ’sold out’, which was not hard to understand considering the event was  hosted at the Keystone Resort in Keystone Colorado. Can you say ‘Rocky Mountain high?’

Major Colbert ‘tip of the hat’ kudos to CHF as the event featured the following health policy wonk industry icons: Susan Dentzer (Health Affairs), Len Nichols, Ph.D. (The New America Foundation), Steffie Woolhandler, MD, MPH (Harvard Medical School) and Uwe E. Reinhardt, PhD (Princeton). For a complete list of the faculty and their presentations, click here.

Three presentations impressed me with their depth, clarity and candor. First up is single payer advocate Steffie Woolhandler, MD, MPH, who confidently presents the data establishing single payer as the sole option that can insure the now 50 million uninsured and not bankrupt the country in the process. Her audio clip is powerful, compelling and difficult to challenge on the merits of her pro single payer thesis. (Note: also on the program was Jeff Lemieux, Senior Vice President for America’s Health Plans aka ‘AHIP’).

Len Nichols, Ph.D., deployed witt and southern charm to address the problems inherent in the public option and chart the argument that viable health reform can only come from the non-ideological center (i.e., not single payor, nor pure ‘market based’ – non government intermediated -solutions). Using MedPAC and other data Nichols highlighted the imperative of reform, while also offering his vision of indicia of an incremental though ‘pluralistic solution’.

Susan Dentzer mastered the challenge of providing a recap and guide to health reform in 37 minutes; she set the tone of what was to come from a stellar cast and well orchestrated series of messages. Her introduction sets the standard for health reform context consideration; listen here.

The quality of the conference was superb and the Colorado Health Foundation’s use of social media and Twitter is to be commended. The one suggestion for enhancement is to consider live streaming the conference via uStream.tv, LiveVideo.com or other video feed server platform (afterall it was sold out). Publishing both the podcasts and the speaker presentations on their site via PDF downloads is also commendable; however, uploading the preso’s to slideshare is an option to consider as well.

The conference boldly models an open approach to sharing vital information that can and should extend beyond the reach of the paid conference attendees in Keystone. Understanding the value proposition of a ‘digital footprint’ (i.e., the deployment of social media tools and it inevitable re-distribution) and openly sharing that content vs. a proprietary content lockdown, is a brave and commendable strategy to support public health.

Thank you Colorado Health Foundation!

In the ‘Twittersphere’ (aka micro-blogging) and blogosphere space we are witnessing increasing conversation into the nature and relevance of social media in general and its optimal application(s) in particular.

Just today we had some lively exchange in a Twitter ‘health care marketing‘ stream, using the #hcmktg hashtag.

As an affinity group primarily of marketeers, though not exclusively, the subtext of the questions generally focus on how can marketing, PR or communications specialists, better apply (i.e., ‘leverage’) this evolving technology in support of their institution’s mission? During these exchanges, we hear intermittent echoes of ROI, and other ‘metrics’ to measure performance, and therefore demonstrate value; particularly to the ‘C-suite” or usual suspect laggers to innovation.

The predominant interest seems to be how to perfect, deploy and manage a platform that essentially adds value to the individual facility or parent system in the aggregate. What might some of these dependent variables (or target outcomes) to measure be? In all likelihood, once we advance beyond image mindshare or service specific broadcasting, the likely ends include:

• improve payor mix
• maximize profitability
• steal share from competitor(s)
• position institution for proactive pursuit of defined or niche customer markets
• reduce re-admission rate (wait, who said that? actually no one yet)
• better integration with medical community
• reduce costs

Don’t get me wrong, I love these tweeps (at least most of them). They are my people, and I delight at being a member of the tribe in occasional good standing as measured by select indicia of ‘twitter love’. Yet, no where in the discussion is the the application of this technology to impact the dyfunctional, often bloated and patently un sustainable business models on which some of their very jobs depend.

Where is the active exploration and application of social media tools to “transform’ or ‘re-engineer” the tapestry of admitted failed business models that constitutute ‘mainstream’ US HealthCare?

If social media tools are not used in service of the purposeful transformation of ‘dsyfunctional’ healthcare delivery and financing paradigms, what value does it add? Absent a values based application of social media technologies, I will answer one the questions posed above: ‘Is Twitter A Fad’? in the affirmative. It will flame out of it’s own weight, and ‘look what I can do’ chatty irrelevance.

In future posts, I intend to craft a draft ‘manifesto’ and welcome your active participation and comment.

We’re entering the fast track phase for the legislative process to meet the deadline presented by the President to the Congress. Courtesy of Trust for America’s Health, is a summary of the probable House and Senate timelines to deliver on the requested legislation.

This includes recaps from the House Energy and Commerce Committee, and initial negotiations of the committees with jurisdiction on the House side: Energy and Commerce, Ways and Means and Education and Labor.  

Please note that timelines and language are always subject to change. 

House Timeline

End of Week of June 15 – Draft bill language is released.  This bill will be referred to three committees- Energy and Commerce; Education and Labor; and Ways and Means

Week of June 22 – Hearings in the 3 committees (possibly at subcommittee level)

Week of June 29 – Recess; negotiations continue

Week of July 6 – Full committee hearings

Week of July 13 – Full committee markups

Week of July 27 – House floor consideration

Senate Health, Education, Labor and Pensions (HELP) Timeline

See summary of “Affordable Health Choices Act“.

Week of June 8th – Committee walkthroughs and hearing/roundtable(s)

Week of June 15th – Series of markups of different components of legislation

Week of June 22nd – Additional markups

Senate Finance Timeline

Week of June 8th – Ongoing bi-partisan member meetings.

Week of June 15th – Committee mark released

Week of June 22nd – Committee markup over several days

Senate Floor Timeline

Week of July 20th – Beginning of consideration on Senate floor

Week of July 27th – Completion of Senate consideration

Draft “tri-committee” (E&C, W&M, Education and Labor) public health provisions

Prevention and wellness

Expands community health centers 

Waives cost-sharing for preventive services in benefits packages 

Creates community-based programs to deliver prevention and wellness services 

Targets community-based programs and new data collection efforts to better

identify and address health disparities 

Strengthens state, local, tribal and territorial public health departments and programs 

Workforce 

Boosts training of primary care doctors and expands pipeline of individuals going into health professions, including primary care, nursing and public health 

Supports workforce diversity efforts 

Expands scholarships and loans for individuals in needed professions and shortage areas 

Draft House Energy and Commerce public health provisions

Workforce - Expand and fully fund current workforce programs including the doctor, nurse and other provider programs.  This will include loans and graduate medical education.

Community health centers - The bill will expand community health centers.

Data collection - The bill will create a new health surveillance office that will identify gaps in federal data collection activities and eventually issue health data on a periodic basis.

Prevention and Wellness Fund – This will build on the prevention and wellness money from the stimulus package.  It has four sections:

HHS will develop a national prevention and wellness strategic plan with specific goals on public health issues such as obesity. 

There will be new research authority to identify and develop the best strategies for addressing the goals. 

The U.S. Preventative Task Force and the Taskforce on Community Prevention will be expanded. 

They develop guideline on specific services such as screenings, and community wide actions. 

A new grant program to implement the taskforce recommendations and new funds to help state health departments.

As has been well documented elsewhere, primarily by the oracle of social media adoption in the healthcare space, aka Ed Bennett, more institutional healthcare providers are putting a toe in the water whether via Twitter, FaceBook, YouTube or the fourth horse in the race, FriendFeed (though not tracked by Ed).

Most are lurking or “monitoring their brand” via select hashtags or semantic filters, or by following those active in the broad range of healthcare or wellness related issues. Others, and the vast majority in my experience, are primarily and sparsely “pushing content” from live surgical tweets to the press release “du jour”, i.e., our new cath lab or latest amenity addition.

Yet very few are participating at the level of engagement wherein “conversations are recognized as markets” per the Cluetrain Manifesto, in which the institution participates authentically with intent to establish and build a personal relationship with its followers or community.

Clearly hospitals and health systems are complex entities for which no one person can consistently speak both with authority and authenticity on behalf of the organization and still keep it “personal”.

By proxy prevailing institutional engagements in social media is typically conducted by a hospital or health system employee who may manage both a personal and institutional account, formally, informally or both.

In my view, the market leader aka “chancellor” in the medium of microblogging participation is @LeeAase of the Mayo Clinic, who also manages the @MayoClinic twitter account.

Lee is prolific in his educational content that is mostly directed to the internal constituency of Mayo, which is increasingly finding external interest in what Mayo is doing for their own institution’s consideration.

If you are a hospital, healthcare facility or parent system considering social media, please take the time to learn what is happening in the “Twittersphere”, and do pay attention to the evolving “agreements” of Twitter-etiquette.

As far as recommendations are concerned, here is a brief list of  ”do’s and “don’ts”:

Do:

1.  Open an account with Twitter, FaceBook, YouTube and FriendFeed, claim your name and protect your brand on these platforms (note: also recommend including uStream.tv or equivalent).

2.  Get started by following people active in the healthcare space.

3.  Study the market, read the ClueTrain Manifesto.

4.  Find a smart, insightful and motivated person to task master the social media cause internally.

5.  Do contribute to the tribe’s knowlege base; this is a young but rapidly evolving industry.

6.  Do consider participating in or sponsoring a “HealthCamp”; where the web 2.0 and health 2.0 conversation meets and thrives.

7.  Do  start tweeting!

Don’t:

1.  Do not open an account and push bursts of press releases, directly or via the many automated tools available, simply broadcasting your wares.

2.  Do not push content into the stream unless you are prepared to respond directly and in a timely manner. Twitter is about engagement not silence, whether intentional or accidental.

3.  Do not act like a silo separate from the community you serve. Be open to what your followers have to offer you, from user feedback to issues relating to cost, quality, access and other consumer experience concerns.