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Recon takes an analytical look behind select developments in healthcare

Deploying analytics in a healthcare world flooded with data

We live in a society with too much data. In the field of market research, the deluge of data is cited as one of the top challenges leaders face as they search for actionable insights hidden in the data. Healthcare is no different. Information content increases with the amount of data that surrounds us, but so too does the noise. And, unfortunately, noise often overwhelms and obscures information as the volume of data grows. Add to that the operational issues we introduce in managing the flood of data, and we

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Readmissions rate fallacy

Today’s piece in Kaiser Health News that hospitals’ readmissions rates are flat appears to suggest various ongoing efforts to cut readmissions are failing and failing badly. According to the Medicare data used by Kaiser, the readmission rate for heart failure was 24.8% in 2008-10 and 24.7% in 2009-11 giving us the 0.1% decline cited by Kaiser. Comparing 2011 to 2008, this is a 0.3% difference, still not sufficient to convince us that there is a real change. But don’t write off those efforts yet as there may be a silver

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Clear Health Alliance: Debut of the for-profit HIV/AIDS special needs plan

Summary HIV Special Needs Plans (SNPs) offer extra layers of services specialized for the HIV/AIDS patient and can generate attractive savings particularly in reduced in-patient costs A new partnership in Miami-Dade is creating a for-profit model in what has historically been a space pursued by mission-oriented non-profits Recent Florida legislation mandating HIV positive Medicaid members join an HMO specialized in HIV/AIDS sharply expands the potential market for SNPs and was likely critical for the for-profit venture In contact to the condition-specific provider ACO, SNPs are likely better suited for addressing

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Rescuing the condition-focused ACO from CMS

Summary The case for an oncology ACO can be compelling but CMS rules for ACOs within fee-for-service (FFS) make value difficult to demonstrate A new physician-hospital-payer partnership in Florida will test whether the oncology ACO model can succeed outside the CMS rules The payer partner has a limited Medicare position and the hospital partner is reputed to be high priced. Despite these potential issues, there are good reasons to think the partners are well aligned on a growth agenda for the model If the model itself proves out, however, it

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Transitioning from patchwork to quilt: NY and PA’s path to integrating HIEs at the state level

Last month, NY and PA announced plans for how they will integrate data sharing across local HIEs. The state planning efforts share some key parameters: Roughly equal funding with about $20 million in federal grants Initially targeting  the integration of data for about 13 million people (in PA’s case the entire state, in NY’s case the NYC metro area) Using a “thin” umbrella model to knit the various existing local HIEs together into a decentralized model Want community involvement of local doctors, community workers, and payers Beyond those parameters, however, the plans look quite different. NY’s approach: Start

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Heartland Health: Marching towards Kansas City with Mayo on its shoulder

Earlier this month, Heartland Health signed a deal with the Mayo Clinic for its doctors to virtually consult cases with Mayo physicians in return for an undisclosed fee. Heartland Health is a regional medical system in northwest Missouri and includes a ~350 bed acute care hospital (Heartland Regional Medical Center) with 200+ medical staff physicians, and the Heartland Clinic with 100 providers in 23 locations.  Heartland is now the fifth hospital system to join the Mayo Clinic Care Network (MCCN), a structure launched by Mayo in September 2011. The deal substantially

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The Blues system and PHIXs: not standardizing on a single utility

BCBSMN has licensed the platform for its private health insurance exchange (PHIX) and defined contribution product from eHealth (original announcement April 30). For eHealth, which has seen its government systems revenue fall off by $2M year-over-year in the most recent quarter (per Q1 2012 analyst call), the deal will be a welcome addition to its non-commission revenue stream. It also represents a significant in-road into the Blues system (the previous deal with Blues I could uncover was in mid-2010 for licensing the technology behind Premera’s online Medsupp sales). It appears

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Towers Watson’s bold move in private insurance exchanges: leapfrog Aon and leave Mercer’s alliance compromised

With its acquisition of Extend Health, Towers Watson has ensured that (1) PHIXs will be a key competitive arena among the major benefits consultants and (2) that it has taken the lead. Extend Health serves 170K members and has annual revenues of ~$50M+, EBITDA margins of ~30% and a growth rate in the most recent reported quarter of 40% vs. a year ago (all taken from the S-1 filing and acquisition press release). Two leading competitors have been publicly discussing their capability building: Aon Hewitt began their exchange in April

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Big box retail as health insurance channel: thoughts on the Aetna-Costco deal

Summary Aetna has struck a deal to sell individual health insurance with Costco, the #6 retailer. The deal targets 9 populous states first with more to follow in 2012  While the deal lacks some of the levers of the very successful Walmart-Humana Part D deal, there is real potential for this channel to attract consumers if employers opt-out on a large scale Given that Aetna has some arrangements with Best Buy (the #9 retailer) and an established alliance with CVS (the #7 retailer), it looks like Aetna is building out

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Payment reform: some observations on skepticism

There have been some blog posts (here and here) about a discussion on payment reform at the Massachusetts Health Data Consortium last week. While I did not attend, the commentary is provocative and I would like to offer a few observations. The discussion included some critical perspectives on the prospects for implementing payment reform and whether its implementation will really bend the trend. My main point in response to the dialog is that payment reform needs to be understood as part of a dynamic trajectory, a multi-stage game. Couple variations

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Franchising specialties: model for breaking down geographic barriers to competition?

Summary Geographic barriers to provider competition are a headache for payers By importing capabilities, specialty franchising could help reduce some of the barriers to cross-geography competition It is too early to tell whether the recent Sarasota-Columbia is a good example of what franchising could do given the rapid growth in capacity for high-end cardiology in the area; it may be more about preserving network status and price point But payers should not assume the model will be a disappointing supplement to provider leverage: Instead, consider encouraging providers with differentiated outcomes

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The ASO escape hatch for small group: California says “not so fast”

Next week, the California insurance commissioner will propose legislation to deter small employers from exiting the traditional health insurance market and going self-insured. The legislation will put a floor on the amount of losses an employer must incur with any one employee before the stop-loss coverage is triggered (“attachment point”). This won’t affect larger employers which benefit from the balancing impact of their large numbers and so only need to protect themselves from the most catastrophic risks. The bottom lines of self-insured smaller employers are much more vulnerable to even

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Home health’s LHC Group decoupling from the stock market: where is it going next?

The PE firm TPG is reportedly considering investing in LHC, a publicly-held home health agency (LHC announced earlier this year they were exploring strategic options). PE funding could allow LHC to pursue a much bolder strategy in the wide-open post-acute care market. Home health With home health revenues of ~$560M, LHC is #3 behind Amedisys ($1.25B) and Gentiva (~$1.1B) and ahead of #4 Almost Family. These four operate in an incredibly fragmented industry of $70B/year (though most of their attention is on the $20B year Medicare FFS market). The vast

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Lumeris, NaviNet and the emerging battle for cloud-based ACO enablement

Summary Administrative clearinghouse NaviNet has been acquired by 3 Blues plans and a provider of analytics capabilities for plans and providers (Lumeris).  Both NaviNet and Lumeris appear to need a strategic breakout. The key opportunity is coupling sophisticated cloud-based (=EMR agnostic) analytics with a real time communications platform touching 130K physician offices.  If viable, cloud approaches to ACO enablement could reduce the upfront infrastructure cost for providers to go at-risk, therefore allowing smaller scale provider groups to participate in the new economics – an attractive proposition for payers unnerved by

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Compete by creating more competitors: the Heartland Health deal and Aetna’s strategic jiu jitsu

Yesterday, Aetna announced a deal with Heartland Health (an integrated delivery system serving northwest Missouri, northeast Kansas and southeast Nebraska) to create a new health plan for the small group market (2-50 employees) for 2 counties in Missouri and 1 county in Kansas. Heartland Health has a ~350 bed acute care hospital (Heartland Regional Medical Center) with 200+ medical staff physicians, and the Heartland Clinic with 100 providers in 23 locations. Most important, recent financial evaluations have given Heartland Health a startling 82% market share in primary service area (!).

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Aetna and Best Buy: a new twist on retail in healthcare

Aetna has struck a deal with Best Buy to sell four online coaching programs (fitness, weight management, smoking cessation and stress management) in new 1,200 sq. ft. “health technology departments” in 3 suburban Chicago locations.   In these departments, Best Buy is selling a broad range of technologies and tools for fitness, sleep, nutrition and beauty alongside the Aetna programs.   The strategy: target Best Buy’s tech savvy customers when they are thinking about health and when they have an expectation to buy (vs. for example being on-line when there is more

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