Posted by on in Population Health, Providers

A clinical vignette: the cases of Jane and Joe Imagine if you will two individuals both at age 50. Jane is a project manager whose recent health care has focused on managing menopausal symptoms, a knee injury sustained while skiing, and moderate episodic depression, with a medication list of one chronic medication, and one medication as needed.  Joe is a bus driver whose recent health care has focused on managing Type II diabetes, hypertension, and low back pain, with a regimen of 4 chronic medications, and 2 medications as needed.  Jane is highly informed and engaged in her care. Read More

Posted by on in Network strategy, Payers, Population Health, Providers

Summary The Capital Region of Pennsylvania is shifting in “real time” from traditionally separate plan vs. plan competition and provider vs. provider competition to integrated vertical plan/provider vs. plan/provider competition Vertically integrated competition can initiate both arms races in delivery system capacity and new product and care management strategies The two big independents – WellSpan and Capital Blue Cross – are trying to match the disruptors with their own capital spend and a vertical alliance Once you cede decisions on terrain and timing to the competitor, you must make do with the options available, not the options you would like. Read More

Posted by on in Network strategy, Payers, Population Health, Providers

By bringing together accountable-minded physicians, urgent care and ambulatory surgery centers (ASCs) on a national scale, OptumCare could prevent a lot of avoidable hospital care and move much of what remains to lower cost sites of service.  Wrap a capitation business model around it and you have a powerful “anti-system” – profitable for itself and toxic to hospital margins. OptumCare has a long way to go to put this theory into practice.  It is still in only ~35 of its target 75 markets.  And, within many of those 35 markets, OptumCare has a major remodeling job:  it lacks… Read More

Posted by on in Biopharma, Payers, Population Health

Working Paper   Summary Drug companies are naturally incentivized to price their drugs under assumptions of optimal clinical value, i.e. as high as possible.  Payers react to this by setting stringent conditions for patient eligibility for coverage of those therapies. As a consequence, patients who do not meet these conditions do not receive those drugs even though they could derive benefit, albeit not of a magnitude that would justify the cost.  Here we lay out a population health based scheme by which payers and drug companies can design a system that ensures access to a drug to a larger group… Read More

Posted by on in NEJM Highlights, Population Health

Disappointing interim results from two ACA experiments Two papers reporting results from ACA experiments – the Comprehensive Primary Care (CPC) Initiative in which primary practices were incentivized with fairly generous payments to strengthen care management activities such as management of chronic conditions, or coordination of care – and the ACO initiatives (2012 cohort) described elsewhere in many reviews. Both papers provide a view on the early impact of these initiatives (2 years out) on costs and outcomes by using well controlled no-intervention comparison groups. The upshot is that so far, the CPC and ACO (v. 2012) initiatives do not show… Read More

Posted by on in Population Health, Providers

It is a long-standing hypothesis shared by many providers that community-based interventions that improve primary care could lead to overall healthcare savings by preventing (or delaying) the occurrence of medically expensive conditions.  Rigorously proving this has been difficult, and only a few appropriately controlled studies have been published. In a Letter to the Editor of the American Journal of Managed Care[1], my colleague Alex Brown and I commented on an earlier article[2] evaluating the impact of a community health worker (CHW) intervention on healthcare costs. The study showed no significant reduction in average cost… Read More

Posted by on in Consumer Health, Digital Health, Medical Devices, Population Health

I have been conducting an informal test for the past year and a half.  And while it has not been a full statistically-significant clinical trial with test and control groups, and “double blind” testing methods, the results have been striking… The way this test works is that when I meet someone new or reconnect with someone I have not seen in a long time, I ask them to describe themselves and then listen carefully to the answer.  Some clear patterns emerge: It’s most common for people, and particularly my American friends and colleagues, to identify themselves by their occupation…as a… Read More

Posted by on in Biopharma, Payers, Population Health, Providers

A couple of years ago, we addressed the question of whether drug companies could use new business models to capture more of the value they create. At the time, we pointed out that drug makers had struggled to get payers interested in new models, and that any potential solution would need to consider aspects of the drug (as it relates to the overall care paradigm and system), and of the payer. Fast forward to 2016, and there are a number of factors that suggest that now may be the right time for drug makers and payers to partner in creating value by sharing clinical and… Read More

Posted by on in Payers, Population Health, Providers, Uncategorized

Correctional health and correctional pharmacy 2.2M people are incarcerated in local jails and state and federal prisons at any one time in the U.S. for whose healthcare various government agencies are responsible. This aggregate number hides some important segment differentiation (see table). Local jails are housing a little over 700K on any average day but typically for a short period of time (on average a month or less), implying over 11M people flowing through the jail system in any one year (boldly assuming few repeated tours). Less than a month is relatively little time to identify and… Read More

Posted by on in Population Health, Providers, Uncategorized

Over eight months between October 2014 and June of this year, Ochsner formalized alliances with five major provider systems in Louisiana. The first wave (with St. Tammany Parish, Terrebonne and Slidell) reinforced Ochsner’s stronghold in New Orleans. The second wave (with Lafayette General and CHRISTUS) secured pathways to markets west along I-10 and the coast and northwest along the I-49 corridor to Shreveport. This collection of alliances — dubbed the Ochsner Health Network (OHN) — is effectively statewide with ~30% of the hospital beds and ~30% of the physicians. Key components of the alliances include: a joint clinically integrated physician… Read More