Moody's Investors Service has downgraded the debt and financial-strength ratings of the parent of Chicago-based Blue Cross and Blue Shield of Illinois. Moody's said Health Care Service Corp., the nation's fourth-largest health insurance company, has been hampered by higher-than-expected medical costs driven by increased unemployment and layoffs that reduced membership. Health Care Service has 12.5 million health plan members and operates Blue Cross and Blue Shield plans in Illinois, Texas, Oklahoma, and New Mexico.
The White House wants to include a national health-insurance exchange in the health bill, which would give House Democrats one of their top remaining demands, according to an official involved in the discussions. At issue is who would run the new insurance exchanges that would allow consumers to comparison-shop for health coverage, the Wall Street Journal reports. The House's version of the health overhaul calls for the federal government to run a single, national exchange, while the Senate's version would let states run their own exchanges.
Democratic leaders negotiating a compromise healthcare bill appear likely to reject a House provision requiring employers to offer generous coverage to their workers or else pay a steep payroll tax, the Boston Globe reports. A handful of moderate Senate Democrats who hold the political upper hand in shaping the final bill are expected to insist on hewing much closer to the Senate's relatively lenient approach, which does not include a strong requirement that employers offer coverage, reports the Globe.
Washington, DC-based United Medical Center is struggling to pay its bills and might need a bailout to stay open, according to DC Council members. The situation at the hospital is so dire that city leaders have begun looking for a new owner for the 184-bed facility. Council members told the Washington Post the hospital has an operating deficit of as much as $20 million, and a bank recently denied its request for a $5 million line of credit.
Aetna Inc. will have lower profits in 2010 than it did in 2009, Aetna Chief Financial Officer Joseph Zubretsky told analysts at the J.P. Morgan Healthcare Conference. Zubretsky said that 2010 is a rebuilding year, as the company works toward returning to annual profits in the high single digits. Zubretsky said that the 2010 forecast doesn't take the passage of healthcare reform into account, but added that recent diversification makes Aetna "well-positioned to take advantage of the transformational change that will take place in the business," the Hartford Courant reports.
In the drive toward better cost and quality decisions, our industry long has been held back by what might be called an information gap.
Providers and payers each have plenty of information, but have poor mechanisms for sharing it in a consistent, meaningful, and timely way. New technologies now make it possible to gather and assimilate massive amounts of information, distill it into useful data streams, infuse it with clinical and business intelligence, and present it in actionable formats to those who need to use it.
Health plans are urgently seeking ways to improve quality while controlling costs. In the past, we were hampered by systems that took months to move data into a warehouse, could not interact with each other, and often contained only claims data. Now, we are seeing next-generation analytics that can draw from multiple sources to meet some of our greatest challenges. We are moving into an era of information that is specific and current.
Newer technologies integrate lab values and point-of-care clinical information—including data from electronic health records. By applying rich clinical rules in the form of evidence-based clinical knowledge and sophisticated algorithms, we can create a more complete view of the patient. Presenting the results to providers rapidly and in a useful format can lead to more effective care for individuals and across populations.
Triggers, prompts, and alerts offer value to both the plan and the provider—and will be embraced by physicians if this information helps them to meet quality benchmarks. For example, a diabetic who is overdue for a hemoglobin A1c test can be flagged for follow-up, so that lab results will be available for an upcoming visit. When a woman is in her primary care doctor's office, an alert might pop up on her chart because she hasn't had her annual mammogram; the interaction is an opportunity for education, and ideally, for scheduling the screening exam on the spot.
Analytics coupled with the ability to reference multiple guidelines can minimize time-consuming and manual interactions between plans and providers. With the appropriate clinical evidence and benchmarks in a utilization report, a plan administrator will be better able to evaluate requests for exceptions and appeals.
But next-generation analytics also can show when a provider consistently deviates from evidence-based care, enabling rapid intervention before cost and quality suffer significantly. For example, if a plan's medical director notices an unusually high rate of deep-vein thrombosis (DVT) in a population, sophisticated analytics would enable the medical director to drill down into the data to identify which providers, which procedures, and even which surgeons are associated with the higher-than-expected rate of this dangerous and costly complication. Sharing the information with the provider is an appropriate first step toward ensuring that preventive measures are taken.
The ideal systems offer configurable dashboards that present data in role-specific ways within the plan and can be pushed to providers via a portal. Systems will be most valuable if they are supported with clinical and business intelligence to produce highly relevant reports that include regional and specialty comparisons. Especially for providers, such reports must demonstrate that clinical knowledge has informed the selection, integration, analysis, and presentation of the information.
Information as a foundation of trust and reform
Physicians, trained as scientists, are skeptical of unfamiliar information. But data that can be shown to be reliable, consistent, and transparent will be accepted—and used as a springboard toward more evidence-based care. Particularly when they're involved in defining metrics, physicians do respond to objective performance data and incentives for providing high-quality, cost-effective care.
As providers become more invested in meeting the cost and quality benchmarks of various reform initiatives, analytics systems will need to support granular, extended clinical reporting. The best of these systems will quickly and accurately integrate appropriate outcomes data for metric-driven incentive programs.
This is especially relevant as payment systems become more complex. Under new and pilot payment models, analytics can help pinpoint those providers that are most suitable to participate, evaluating for such characteristics as patient volume, quality measures, and geographic area served.
In a "bundled payment" initiative, for example, where reimbursement for facility, professional, and allied services may be incorporated in a single payment, analytics are needed to verify provider experience with a particular procedure or treatment, to ensure the right expertise is available for the services that are defined in the bundle. Enabling providers to look into their own data and anonymous comparative data will be very useful, especially in explaining why some providers may not qualify for a particular program.
Other reform-minded initiatives will be enhanced by more robust analytics, which also can then measure a program's success and cost-effectiveness. Consider disease management: Analytics that integrate clinical and claims data will help assess which patients might benefit from disease management programs. Analytics can assess whether interventions met expectations and what areas might need fine-tuning.
Keeping up with the genome
As medical information grows and medicine becomes more personalized, even the most conscientious physician will not be able to keep up with the flood of information needed to make informed decisions. Within the next few years, treatment of a single individual's hypertension may evaluate more than a hundred genomic markers.
Looking forward, analytics likely will play a role in understanding which tests are appropriate for which patients and at what time. Eventually, we will be looking to systems to compare the actual gene sequence (the genotype) with the clinical expression of an anomaly (the phenotype). This will require a great deal of computational muscle, but offers benefits financially and in optimizing care.
For now, the next generation of analytics will connect providers and payers with shared information from a multi-sourced central repository and produce configurable reports that deliver the right information to the right people at the right time. For decades, plans told providers, "We don't have the data." The data is there now and new analytics can help us harness and communicate that data to drive better clinical care decisions.
Douglas Moeller, MD, is medical director at McKesson Health Solutions in Malvern, PA.