Category Archives: health market quality

A chat with Terry

An excerpt of a conversation with Terry Hannan on the business and bureaucracy of health and clinical care…

 

Terry, thank you for sharing those terrific papers by John Wennberg and Brent James… inspiring and affirming thinking.

 

Regarding your request for me to expand on how “true” priorities of the system are expressed:

My overarching thesis for eHealth and its myriad follies is that the systems built often correctly reflect the “true” priorities of the system. The only glitch is that these priorities are often so radically divorced from those stated by the system’s leaders and in turn expected by clinicians and/or the public.[I would like you to expand this # as I am not sure I entirely grasp your focus here.]

 

Different stakeholders expect different returns from their investments. Roughly speaking (and apologies in advance for some of the generalisations that follow):

– politicians want to maximise votes in return for policy announcements

– bureaucrats want to maximise budget, status and power, and minimise risk in return to turning up to work

– public sector doctors want to maximise the health of their patients and status in return for turning up to work and working hard

– private sector doctors want to maximise income and status and minimise legal exposures in return for doing as much work as possible

– private hospitals want to maximise revenue in return for getting as many patients through their doors as possible

– nurses unions want to maximise members in return for negotiating improved work conditions

– not-for-profit (mutual) private health insurers want to maximise their perks by keeping doctors and private hospitals happy

– for-profit private health insurers want to maximise their profit margins by minimising doctor and hospital payments and maximising membership

– health researchers want to maximise their research capacity in return for increased publications

 

(Patients don’t even make my list of stakeholders, because they are not truly involved at present. An interesting remedy for this is citizen juries, a discussion for another time – did you ever engage with Prof Gavin Mooney before his untimely death?)

 

This suggests that each of these tribes wants a different “currency” in exchange for the “value” they deliver to the health system. They all use “patient interest” as the public justification for their claims on the system, but most of them are not actually remunerated in a currency that relates to the patient’s interest.

 

Indeed, in true “rent seeking” fashion, most of these stakeholders would rather not have to justify their remuneration to anyone – see this recent HLM news article.

 

At present, the easiest way to see what the system actually values is by looking at what it invests in. One “tell” that belies the health system’s “true” priorities is what it goes to the effort to properly records in electronic form i.e. billing data. This therefore suggests that money is the priority, and so it is what is tracked carefully.

 

If “patient interest” was truly the priority of the system, then far more effort and expense would be put into tracking patient outcomes, and in time, paying for them. On this, I am encouraged by the early shoots starting to sprout in the US around the development of ACOs, though I’m sure there are a lot more warts on it when seen up close.

 

My favourite “tale” of how to get there relates to how I’m told traditional chinese medical practitioners used to be paid. Everyone in the village would pay the practitioner as long as they were well, but stopped paying them whenever they ever got sick. This tight pecuniary alignment between patient and practitioner interest excites me, and makes me think there is still hope for ACO-style reform here. Indeed, my current health policy horizon doesn’t even involve hospitals and doctors, but rather looks at prevention efforts as the focus, as separate system with separate funding and separate participants.

 

I suspect this is best discussed over a long lunch or dinner, which I look forward to when the opportunity next arises.

 

Best regards, Paul

 

 

 

 

 

 

 

From: Hannan, Terry J (DHHS) [mailto:Terry.Hannan@dhhs.tas.gov.au]
Sent: Tuesday, 17 June 2014 9:07 PM
To: Paul Nicolarakis
Subject: RE: contact

 

See my inserted notes.

 

From: Paul Nicolarakis [mailto:pnicolarakis@cmcrc.com]
Sent: Tuesday, 17 June 2014 5:45 PM
To: Hannan, Terry J (DHHS)
Subject: RE: contact

 

Thanks for your forbearance Terry.

 

I’m inspired by your resilience and enthusiasm for the area, and quite certain that this particular eHealth conversation is going to yield some interesting insights. I present these ideas (which tend towards the political more than technical or clinical) to you in confidence, with a view to sharpening up the thinking. In light of my political experience, I would not want to offend any past masters as they were operating within some diabolical constraints.

 

My overarching thesis for eHealth and its myriad follies is that the systems built often correctly reflect the “true” priorities of the system. The only glitch is that these priorities are often so radically divorced from those stated by the system’s leaders and in turn expected by clinicians and/or the public.

 

Applying this analysis, it makes sense that an EMR purpose built to support HIV treatment in Africa would work because the only people involved in its development are dedicated clinicians, developers and minimal funding from similarly aligned entities with the specific purpose of improving the quality of care.

 

It also makes sense that physician led, integrated health systems (e.g. Regenstrief, Intermountain) that understand the “triple aim” nexus between high quality care and reduced costs would employ these systems successfully.

 

But finally, it also follows that systems built for governments in modern western democratic economies will never work because they are being built to get their political leaders re-elected, and make their vendors lots of money, but not really serve the community. The failure of these systems is ultimately guaranteed when the transparency they risk introducing into a system starts to threaten vested interests such as private medical providers and their associated institutions.

 

As per your slide from Blum, the red tail wags the yellow and blue dog because this is actually what matters in modern health care.

 

Microsoft learned this the hard way with their health solutions group efforts that I was involved in for a few years. The analytics software (Amalga) was quite impressive, initially developed by a group of keen, inquisitive (“data curious”) emergency physicians. They used the solution to monitor all sorts of clinical quality metrics across the business Washington Hospital Center service. Microsoft executives saw it, were impressed and acquired it. They then tried for 4 years to sell it to the world, only to discover that the “world” was not as interested in “clinical quality” as they were in bottom line revenues. What emerged from this experiment was the realisation that Microsoft had found itself ambushed by the gross conceit of modern healthcare i.e. stating that it was all about patient care, when in actual fact it was all about cash. Hence the highly administrative focus of most EMRs?

 

What has been terrific is to see US policy makers respond to this realisation by establishing “business models” around meaningful use and clinical outcomes. This is what seriously excites me now, though I suspect Australia is a decade away from adopting anything like what’s going on in the US at the moment.

 

One of the mantras we have here at the CRC (born in part out of our academic finance roots) is: “Healthcare is not a system, it’s a series of highly dysfunctional markets”. Applying this prism to healthcare really does start to clarify things, especially on the private side. On the public side, the currencies are sometimes different, but no less predictable.

 

I’ll pause here for fear of triggering some sort of global terrorist alert and/or offending you? Needless to say, I look forward to seeing where this conversation goes!

 

Best regards, Paul

 

 

 

From: Hannan, Terry J (DHHS) [mailto:Terry.Hannan@dhhs.tas.gov.au]
Sent: Tuesday, 17 June 2014 2:15 PM
To: Paul Nicolarakis
Subject: Re: contact

 

Take your time you just spark my enthusiasm. The fact that you are interested is such joy. Terry

Sent from my iPhone Terry Hannan
On 17 Jun 2014, at 1:40 pm, “Paul Nicolarakis” <pnicolarakis@cmcrc.com> wrote:

Please bear with me Terry… I’ve got lots on at work… will respond soon… Paul

 

From: Hannan, Terry J (DHHS) [mailto:Terry.Hannan@dhhs.tas.gov.au]
Sent: Monday, 16 June 2014 2:12 PM
To: Paul Nicolarakis
Subject: RE: contact

 

Paul, thank you for the taking the time to write to me and if you think about it this is the first time in our long association where we have done a bit of eHealth “together”.

Based on your enthusiasm in the text I will now send you some materials which should further extend our discussions.

 

Firstly I have attached nan short slide set that I had prepared for the Sydney meeting-just in case.

The next slide is explained in the text flowing it.

<image001.png>

 

This slide is taken from B. Blum’s Clinical Information Systems and you can see the small RED Administrativebox in the top left which is where most HIS funding and management comes from and they try to meet the needs of the most important cost generator Clinical Decision Making.

This is confirmed by the work in cost reduction in CDSS as shown in the slide set attached by Tierney in Regenstrief.

Also in the references below.

1.         Slack WV. Cybermedicine, How Computing Empowers Doctors and Patients for Better Health Care. 2nd ed. San Francisco: Jossey-Bass; 2001 2001.

2.         Tierney WM, Fitzgerald JF, Miller ME, James MK, McDonald CJ. Predicting inpatient costs with admitting clinical data. Med Care. 1995;33(1):1-14. Epub 1995/01/01.

3.         Tierney WM, Overhage JM, Takesue BY, Harris LE, Murray MD, Vargo DL, et al. Computerizing guidelines to improve care and patient outcomes: the example of heart failure. J Am Med Inform Assoc. 1995;2(5):316-22. Epub 1995/09/01.

 

In addition these results from institutions such as Regenstrief, Intermountain Health (HELP System), Brigham’ and Women’s Hospital and Beth Israel Deaconess Hospitals confirm these findings and show that the current funding models by governments are incorrect.

 

I am attaching two summary papers from the Kenyan project.

I hope I have not burdened you.

 

Terry

Dr Terry J. Hannan MBBS;FRACP;FACHI;FACMI
Consultant Physician
Clinical Associate Professor  School of Human Health Sciences, University of Tasmania Department of Medicine, Launceston General Hospital
Charles Street Launceston 7250

Moderator: http://www.ghdonline.org/

Ph. 61 3 6348 7578
Mob. 0417 144 881
Fax 61 3 6348 7577
Email terry.hannan@dhhs.tas.gov.au

Skype: thehannans

 

From: Paul Nicolarakis [mailto:pnicolarakis@cmcrc.com]
Sent: Monday, 16 June 2014 1:33 PM
To: Hannan, Terry J (DHHS)
Subject: RE: contact

Paper (PDF): Are docs the weakness in the ehealth building

Dear Terry,

Thank you for sharing the paper and referring me to ghdonline.org – I’ve just signed up.

The paper touches on many issues close to my heart, but two that I am particularly interested in is the exploration of “healthcare as business” vs “the business of clinical care”.

I won’t commit my dismal views to this email for fear of offending due to lack of context, but would welcome an opportunity to a vigorous discussion with you when we next have an opportunity? To the discourse I would like to add “healthcare as a bureaucracy” and “the bureaucracy of clinical care” as I believe this frame paired with “business” frame are particularly explanatory of most things that happen (or in the case of e-health, don’t happen) in the sector. Needless to say, the clinical and information systems you helped to establish in Africa represent something of an ideal in my mind for an end-goal of a “lite”, modern, effective health system following the “less is more” maxim.

Looking forward to continuing the conversation.

Best regards, Paul

I’ve now seen the Australian health system laid bare while working for the Minister, and many other health systems up close while working internationally at Microsoft. I’ve concluded that with rare exceptions, health care represents “just another unremarkable business” or “just another unremarkable

bureaucracy” depending on the type of funding system that is used.

Menadue: Auction off provider numbers

Now there’s an interesting thought:

Another option to overcome shortages of doctors in rural Australia would be to auction provider numbers by postcode but that would probably be too radical for many professional people who don’t like open markets.

John Menadue. Have we too many doctors?

John Menadue. Have we too many doctors?

There are no international comparisons that I can find that show that we have a shortage of doctors in Australia. In fact, we may be moving into a situation of having a surplus of doctors.  In its “Health at a glance” the OECD found that we are above the average in our supply of doctors. The OECD provided details of “practising doctors per 1000 of population in 2011” for over 40 major countries. The OECD average was 3.2 practising doctors per1000 of population. Australia was slightly above the average with3.3 practising doctor’s per1000 of population. For the Netherlands it was 3.0, for the UK 2.8, for NZ 2.6 and Canada 2.4. The top four countries with over 4 practising doctors per 1000 were Greece, Russia, Austria and Italy. The OECD is quite explicit about trends in Australia It says “in several countries (e.g. Australia, Canada, Denmark, the Netherlands and the UK) the number of medical graduates has risen strongly since 2000 reflecting past decisions to expand training capacity…In Australia the number of medical graduates has increased two and a half times between 1990 and 2010 with most of the growth occurring since 2000”

In 2004 when Tony Abbott was Minister for Health he decided against advice that we had a shortage of doctors. As a result the number of domestic students graduating from medical schools in Australia increased dramatically from 1,287 in 2004 to 2,507 in 2011. It has been described as a “tsunami” of medical graduates. The OECD found that in 2011 with 12.1 medical graduates per 10,000 of population we were well above the OECD average of 10.6. We know that this increase in numbers is making it very difficult to find training places for the increased number of medical graduates.

We also know that with bulk billing and with patient dependence on the advice of their doctor about future appointments, tests and referrals, doctors have an ability to generate work for themselves and other professionals. Doctors can and do drive the demand for their services through fee for service.  That has serious cost implications.
Apart from the total numbers the other important issue is the distribution of doctors across Australia.  All the data shows serious shortages of doctors and other health professionals in rural and remote Australia. These shortages are occurring despite the fact that we now have about 3,000 International Medical Graduates (IMGs) who are tied to areas of need. These IMGs have performed a useful role in rural areas although there has been some concern over language and sometimes professional skills. However it seems logical and legally defensible (“civil conscription”) that if we can determine where IMGs can work, why can’t we do the same for Australian medical graduates and insist that new provider numbers only be issued according to need in Australia. We don’t need more provider numbers and doctors in Belleview Hill and Toorak, but we do need them in rural and remote Australia.  Through governments, taxpayers subsidise medical education and about 80% of the remuneration of doctors comes from government. There is a legitimate interest in new doctors working in areas of need, at least in the early stages of their career. Hopefully they will find professional and personal satisfaction in country areas and decide to stay.

Another option to overcome shortages of doctors in rural Australia would be to auction provider numbers by postcode but that would probably be too radical for many professional people who don’t like open markets.

In short we are moving to a surplus in the total number of practising doctors but serious shortages still exist in rural and remote Australia which could be addressed, at least in part by limiting new provider numbers to areas of need.

Why can we send teachers to areas of need but not doctors?

Better prostate ca. markers in seminal fluid than PSA

The urologists will not be happy, ‘fuckers:

The men tested were already considered to be candidates for prostate cancer according to their prostate-specific-antigen (PSA) test results. Biopsy later confirmed that 32 of the men had cancer and 28 did not.

http://www.medicalobserver.com.au/news/seminal-fluid-markers-more-accurate-than-psa

Seminal fluid markers more accurate than PSA

BIOMARKERS in seminal fluid have been found to be a more accurate indicator of prostate cancer than standard PSA testing, according to results from an Australian study.

Researchers from the Freemasons Foundation Centre for Men’s Health at the University of Adelaide tested semen samples from 60 men for a range of ribonucleic acid (RNA) molecules or microRNAs that are known to be increased in prostate tumours.

The men tested were already considered to be candidates for prostate cancer according to their prostate-specific-antigen (PSA) test results. Biopsy later confirmed that 32 of the men had cancer and 28 did not.

University of Adelaide research fellow and lead author of the study, Dr Luke Selth said that the results of the study indicated that, in the men tested, each of the micro-RNAs alone was a better predictor of a cancer diagnosis via biopsy than the PSA test. In addition, several of the micro-RNAs, when added to the PSA test results, were a better predictor of the presence of cancer than the PSA test alone.

Dr Selth said the results were promising both in terms of detecting the presence of cancer and identifying aggressive subtypes which could help to reduce both over-diagnosis and over-treatment of suspected prostate cancer.

“The presence of these microRNAs enabled us to more accurately discriminate between patients who had cancer and those who didn’t, compared with a standard PSA test,” Dr Selth said.

“We also found that the one specific microRNA, miR-200b, could distinguish between men with low grade and higher grade tumours. This is important because, as a potential prognostic tool, it will help to indicate the urgency and type of treatment required.”

The results add to previous research which indicated that microRNAs in blood can predict men who are likely to relapse after surgery for prostate cancer. The team have now applied for funding for a larger study into the role of microRNA biomarkers in predicting prostate cancer.

“We are not at the stage where we can say there is a new test for prostate cancer just around the corner,” Dr Selth said. “While these results are encouraging and exciting, we need to validate them in a much larger cohort.”

Endocr Relat Cancer 2014; online 23 May 

Endemic upcoding in the US

PDF: oei-04-10-00181_HHS Physician Overpayment

http://www.healthleadersmedia.com/content/HEP-305080/Medicare-Overpaid-Physicians-67B-For-Miscoded-Claims

Medicare Overpaid Physicians $6.7B For Miscoded Claims

Cheryl Clark, for HealthLeaders Media , May 30, 2014

An examination of medical claims records by federal officials finds that more than half of doctors’ claims for patient evaluations and related services had incorrect codes or lacked the necessary documentation.

Suggesting physician upcoding practices on a major scale, an Office of Inspector General report Thursday said Medicare overpaid physicians $6.7 billion in 2010.

The overpayments were claims reimbursements for evaluation and management (E/M) services submitted with frequently exaggerated severity codes, the report said.

After examining medical records for a large sample of those claims, the OIG found that 26% of the claims were upcoded to reflect a higher level of severity than what was justified by the patient’s record, amounting to $4.6 billion in overpayments. Another 14.5% were downcoded, reflecting a lower level of severity than what was warranted, for an underpayment of $1.8 billion.

Another 12% of the claims were insufficiently documented, which meant Medicare overpaid $2.6 billion and 7% were undocumented, representing $2 billion in overpayments. About 2% of claims had other coding errors, amounting to about $500 million in overpayments.

In all, 55% of claims for E/M services had incorrect codes or lacked the necessary documentation.

Medicare paid $32.3 billion for E/M services in 2010, an amount that represented 30% of all Part B payments that year.

Severity CPT coding or Current Procedural Terminology, is determined by federal guidelines, and is based on seven factors: patient history, physical examination, medical decision-making complexity, counseling, coordination of care, the nature of the patient’s problems, and the amount of time.

The OIG looked at claims from two types of physicians to draw its conclusions. The first group comprised a sample from 828,646 claims billed by physicians with a history of high-coded claims. The doctors in this group were in the top 1% of their primary specialties and billed at the two highest level codes (4 and 5) for E/M services at least 95% of the time.

The second and larger group sampled nearly 369 million claims from doctors without a history of high coding. Physicians can score CPT codes at levels from one to five, but for this review, the OIG limited its scrutiny to those visits coded at level 3, 4, or 5.

From both groups, a sample of 673 claims were examined in detail to determine the justification for higher codes.

The OIG review found more inappropriate coding within the first group of doctors—those with a history of submitting high-coded claims.

The report informed the Centers for Medicare & Medicaid Services that it should do a better job to

  • Educate physicians on coding and documentation requirements, including consolidation of two somewhat different CMS Documentation Guideline manuals issued in 1995 and 1997.
  • Continue to encourage audit contractors to review E/M service billings from physicians with a history of high coding claims
  • Follow up on claims for E/M services to correct errors.

In a response, attached to the OIG report, CMS Administrator Marilyn Tavenner said she did not agree that CMS should encourage contractors to target physicians with a history of high-coding practices, saying such a practice “has resulted in a negative return on investment to CMS.”

The agency also said that the per-claim overpayment amount is “approximately $33,” and since four-year claim reopening period window is about to close for this period covering 2010, the OIG should turn over to the agency the provider number, claim payment amount, correct code for each claim, overpayment amount, Medicare contractor number, claim paid date and other details.

After that information is received, CMS said, it would “analyze each overpayment to determine which claims exceed CMS recovery threshold and can be collected consistent with agency’s policies and procedures.”


Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists. 
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Copyright © HealthleadersMedia, 2014

On the Good Occupational Sociopath

 

From: http://aushealthit.blogspot.sg/2014/06/senate-estimates-hearing-june-3-2014-e.html

The modus operandi of ‘good’ occupational sociopaths is to convince everyone that all is well, “trust us we know what we are doing”. 

The underlying goal is to create as much havoc and confusion as possible, to frustrate, undermine and destroy, whilst on the surface all the while going about their business in a way that looks like we all think they know what the are doing.

Quod erat demonstrandum

McKinsey: Feeding consumer decisions…

Will be useful to plug this into our health market quality explorations…

PDF: Digitizing the consumer decision journey McKinsey

http://www.mckinsey.com/Insights/Marketing_Sales/Digitizing_the_consumer_decision_journey?cid=DigitalEdge-eml-alt-mip-mck-oth-1406

Digitizing the consumer decision journey

In a world where physical and virtual environments are rapidly converging, companies need to meet customer needs anytime, anywhere. Here’s how.

June 2014 | byEdwin van Bommel, David Edelman, and Kelly Ungerman

Many of the executives we speak with in banking, retail, and other sectors are still struggling to devise the perfect cross-channel experiences for their customers—experiences that take advantage of digitization to provide customers with targeted, just-in-time product or service information in an effective and seamless way.

Video

How consumer behavior keeps changing

McKinsey’s David Edelman explains how purchasing decisions are made in a digital world.

This quest for marketing perfection is not in vain—during the next five years or so, we’re likely to see a radical integration of the consumer experience across physical and virtual environments. Already, the consumer decision journey has been altered by the ubiquity of big data, the Internet of Things, and advances in web coding and design.1 Customers now have endless online and off-line options for researching and buying new products and services, all at their fingertips 24/7. Under this scenario, digital channels no longer just represent “a cheaper way” to interact with customers; they are critical for executing promotions, stimulating sales, and increasing market share. By 2016, the web will influence more than half of all retail transactions, representing a potential sales opportunity of almost $2 trillion.2

Companies can be lulled into thinking they’re already doing everything right. Most know how to think through customer search needs or have ramped up their use of social media. Some are even “engineering” advocacy—creating easy, automatic ways for consumers to post reviews or otherwise characterize their engagement with a brand.

Yet tools and standards are changing faster than companies can react. Customers will soon be able to search for products by image, voice, and gesture; automatically participate in others’ transactions; and find new opportunities via devices that augment their reality (think Google Glass). How companies engage customers in these digital channels matters profoundly—not just because of the immediate opportunities to convert interest to sales but because two-thirds of the decisions customers make are informed by the quality of their experiences all along their journey, according to research by our colleagues.3

To keep up with rapid technology cycles and improve their multiplatform marketing efforts, companies need to take a different approach to managing the consumer decision journey—one that embraces the speed that digitization brings and focuses on capabilities in three areas:

  • Discover. Many of the executives we’ve spoken with admit they are still more facile with data capture than data crunching. Companies must apply advanced analytics to the large amount of structured and unstructured data at their disposal to gain a 360-degree view of their customers. Their engagement strategies should be based on an empirical analysis of customers’ recent behaviors and past experiences with the company, as well as the signals embedded in customers’ mobile or social-media data.
  • Design. Consumers now have much more control over where they will focus their attention, so companies need to craft a compelling customer experience in which all interactions are expressly tailored to a customer’s stage in his or her decision journey.
  • Deliver. “Always on” marketing programs, in which companies engage with customers in exactly the right way at any contact point along the journey, require agile teams of experts in analytics and information technologies, marketing, and experience design. These cross-functional teams need strong collaborative and communication skills and a relentless commitment to iterative testing, learning, and scaling—at a pace that many companies may find challenging.

Let’s consider what an optimized cross-channel experience could look like when companies target improved capabilities in these three areas.

A new normal …

Imagine that a couple has just bought its first home and is now looking to purchase a washer and a dryer. Mike and Linda start their journey by visiting several big-box retailers’ websites. At one store’s site, they identify three models they are interested in and save them to a “wish list.” Because space in their starter home is limited—and because it is a relatively big purchase in their eyes—they decide they need to see the items in person.

Under an optimized cross-channel experience, the couple could find the nearest physical outlet on the retailer’s website, get directions using Google Maps, and drive over to view the desired products. Even before they walk through the doors, a transmitter mounted at the retailer’s entrance identifies Mike and Linda and sends a push alert to their cell phones welcoming them and providing them with personalized offers and recommendations based on their history with the store. In this case, they receive quick links to the wish list they created, as well as updated specs and prices for the washers and dryers that they had shown interest in (captured in their click trails on the store’s website). Additionally, they receive notification of a sale—“15 percent off selected brand appliances, today only”—that applies to two of the items they had added to their wish list.

When they tap on the wish list, the app provides a store map directing Mike and Linda to the appliances section and a “call button” to speak with an expert. They meet with the salesperson, ask some questions, take some measurements, and close in on a particular model and brand of washer and dryer. Because the store employs sophisticated tagging technologies, information about the washer and dryer has automatically been synced with other applications on the couple’s mobile phones—they can scan reviews using their Consumer Reports app, text their parents for advice, ask Facebook friends to weigh in on the purchase, and compare the retailer’s prices against others. Mike and Linda can also take advantage of a “virtual designer” function on the retailer’s mobile app that, with the entry of just a few key pieces of information about room size and decor, allows them to preview how the washer and dryer might look in their home.

All the input is favorable, so the couple decides to take advantage of the 15 percent offer and buy the appliances. They use Mike’s “smartwatch” to authenticate payment. They walk out of the store with a date and time for delivery; a week later, on the designated day, they receive confirmation that a truck is in their area and that they will be texted within a half hour of arrival time—no need to cancel other plans just to wait for the washer and dryer to arrive. Three weeks after that, the couple gets a message from the retailer with offers for other appliances and home-improvement services tailored toward first-year home owners. And the cycle begins again.

… requires new capabilities

As this example makes clear, the forces enabling consumers to expect real-time engagement are unstoppable. Across the entire customer journey, every touchpoint is a brand experience and an opportunity to engage the consumer—and digital touchpoints just keep multiplying. To maximize digital channels, companies need to focus on improving their “3-D” capabilities.

Discover: Build an analytic engine

Even in this era of big data and widespread digitization of customer information, some companies still lack a 360-degree view of the people who buy their products and services. They typically measure the performance of direct sales activities such as product pitches and encourage downloads using “last-action attribution” analyses, which assess campaigns in isolation rather than in the context of the entire cross-channel consumer decision journey. Usually these data will have been stored in disparate locations and legacy systems rather than in a central server. Complicating matters further is the range and quantity of unstructured data out there—information about consumers’ behaviors and preferences that is, for instance, captured in online reviews and social-media posts. In our experience, this type of data is usually the least understood and therefore the least utilized by companies.

To get the full customer portrait rather than just a series of snapshots, companies need a central data mart that combines all the contacts a customer has with a brand: basic consumer data plus information about transactions, browsing history, and customer-service interactions (for an illustrative example of how companies can lose potential customers by failing to optimize digital channels, see exhibit). Tools like Clickfox and Teradata can help marketers gather these data and begin to pinpoint opportunities to engage more effectively with consumers across the decision journey. This collection effort requires input from people across multiple functions—a complex undertaking, to be sure, but the payoff can be big. Our work in this area suggests that the growth rate of earnings before interest, tax, depreciation, and amortization of grocers that focus on customer analytics is 11 percent, compared with just 3 percent on average for their main competitors. For big-box retailers, the difference is 10 percent compared with 2 percent.4

Exhibit

Failure to optimize digital channels may result in underperformance.

With a comprehensive data set in hand, companies can undertake the sort of quick-hit “shop diagnostics” that many tell us is lacking in their marketing and e-commerce programs. Using analytic applications such as SAS and R, and by applying various algorithms and models to longitudinal data, companies can better model the cost of their marketing efforts, find the most effective journey patterns, spot potential dropout points, and identify new customer segments. Based on its analysis of click-through behaviors, for instance, one regional retailer saw that a particular set of customers preferred digital shopping over physical and always read e-mail on Saturdays, and so the retailer altered its e-mail campaign to send this cohort online offers only on Saturdays.

Additionally, by using business-process software and services from vendors such as Adobe Systems, ExactTarget, Pegasystems, and Responsys, companies can identify in real time the basic “triggers” for what individual customers need and value—regardless of the product or service—and personalize their approach when making cross- or up-sell offers. They can also use these tools to generate automated reports that track customer trends and key performance indicators. For instance, the regional retailer’s analytics suggested that two of the customers who read their e-mail only on Saturdays were in the midst of a career change; both had revised their profiles on LinkedIn within the past three days. Based on its analytics efforts, the company was able to create targeted offers for each—one received information about laptop bags (based on her previous purchases) while the other received information about suits (based on his previous purchases).

Already, the companies employing these types of advanced analytics have seen significantly improved click-through rates and higher conversion rates (between three and ten times the average). Additionally, McKinsey analysis shows that using data to make better marketing decisions can increase marketing productivity by between 15 and 20 percent—that’s as much as $200 billion given the average annual global marketing spend of $1 trillion.5

Design: Create frictionless experiences

Careful orchestration of the consumer decision journey is incredibly complex given the varying expectations, messages, and capabilities associated with each channel. According to published reports, 48 percent of US consumers believe companies need to do a better job of integrating their online and off-line experiences. There is a premium for getting this right. One major bank unlocked more than $300 million in additional margins by making better use of digital channels. It tapped into underutilized customer data and delivered targeted marketing messages at various points in the purchase-decision process. The bank used the data, plus various personalization and testing tools, to inform changes in marketing campaigns for certain product lines; every next step for every customer was progressively tailored to help the customer take the best action.

Digital natives such as Amazon, eBay, and Google have been leading the pack in resetting consumers’ expectations for cross-channel convenience. (Think of eBay’s Now mobile app, which provides one-touch ordering from any of eBay’s retail partners and same-day delivery in some US cities, or Amazon’s recent incorporation of a help button in the company’s latest-generation Kindle Fire tablet, linking users to a live help-desk representative.) These players have perfected the ability to test new user experiences and constantly evolve their offers—often for segments of one.

This lean, start-up approach might sound counterintuitive to large, entrenched marketing organizations in which decisions are made at a snail’s pace, but test-and-learn methods can help companies decide how best to optimize (and customize) critical design attributes of the consumer decision journey at various points along the way. In the appliances example discussed earlier, the retailer’s customer analytics allowed it to design an experience for the couple that was completely customized to their context—from their initial online searches to their physical and virtual interactions at the store and to their follow-up with the company postpurchase. Rather than push what could be construed as intrusive (even creepy) messaging, the retailer provided Mike and Linda with the most useful information at every point in their decision journey and offered the easiest possible path to purchase and delivery.

To create similarly frictionless experiences, some companies have created 24/7 digital “window shops” to test product ideas and customer interactions and collect rapid feedback without the need for additional labor or inventory. Several companies that offer inherently complex products or services have incorporated “gaming” elements into their experiences—tweaking the navigation, content architecture, and visual presentation to allow consumers to trade off and test various options and prices associated with a product before making a decision. One financial-services firm redesigned its mobile app for collecting credit-card applications to incorporate the customer context. Previously it had a one-size-fits-all interface; in the redesigned version, various elements of the mobile app’s interface—such as pricing, stage of process, and designated credit limits—are dynamically generated based on existing customer information. And the app’s page layout and navigation are rendered simply, allowing for easy completion within just a few clicks. The result has been a significant uptick in online applications.

Deliver: Build a more agile organization

In our experience, too many companies are afraid to launch “good enough” campaigns—ones that are continually refined as customers’ purchase behaviors and stated preferences change. Under the direction of conservative senior leaders, teams tend to launch campaigns that take too long to get off the ground and end up revealing few new insights. Instead, they must be willing to conduct lots of small-scale experiments with cloud or proxy website services to pilot new designs and prove their value for investment.

These types of agile, data-driven activities must be supported by an organization that has the right people, tools, and processes. Many companies will have some of the talent required, but not all, and executives will inevitably face resistance when it comes to introducing lean tools and techniques into their sales, marketing, and IT processes. The most successful omnichannel marketers we’ve seen have established centers of excellence in both analytics and digital marketing, and they practice end-to-end management of microcampaigns. Their campaign-building processes typically include systematic calendaring, brainstorming, and evaluation sessions to allow for one-week and two-week turnaround times. And roles and responsibilities are clearly defined. Far from creating a rigid, hierarchical process, this model frees up individuals to iterate quickly—what is sometimes called “failing fast forward” in the world of high tech.

At one bank, for instance, business-unit leaders gather each month to talk about their progress in improving different consumer journeys. As new products and campaigns are launched, the team places a laminated card illustrating the journey at the center of the conference-room table and discusses its assumptions about the flow of the experience for different segments and about how the various functional groups need to contribute: Where does customer data need to be captured and reused later? How will the design of the campaign flow from mass media to social media and then on to the website? What is the follow-up experience once a customer sets up an account? The team has also appointed dedicated mobile and social-media executives to become evangelists for strengthening the omnichannel experience, helping business units raise their game along a range of consumer interactions. The company’s first wave of fixes and new programs generated tens of millions of dollars in the first six months, and the team expects it to continue scaling beyond $100 million in added annual margins.

Building an agile marketing organization will take time, of course. Companies should start by assembling a “scrum team” that will bring the right people together to test, learn, and scale. The team should incorporate cross-functional perspectives (marketing, e-commerce, IT, channel management, finance, and legal), and its members must adopt a war-room mentality—for instance, making tough calls about which campaigns are working and which aren’t, and which messages should take priority for which segments; launching new tests every week rather than every six months; and mustering the IT and design resources to create content for every possible type of interaction.

Companies likely will need to hire people with skills that differ from the ones they rely on now. Some organizations have developed innovative, venture capital–like strategies for finding and recruiting the people they need. Staples, for instance, has built an e-commerce innovation center in Cambridge, Massachusetts, to better recruit technology talent from nearby Harvard University and MIT, and it recently bought conversion-marketing start-up Runa to act as a talent hub on the West Coast.

New types of information systems may also be required. The best technology solutions will vary according to a company’s starting point and objectives. Generally, though, companies will get the best results from tools that enable large-scale data management and the integration of databases; the generation of next-best-action and other types of advanced analyses; and simpler campaign testing, execution, and metrics.

Companies need to make strategic decisions about the best pathways to build customer value. Many cite digital as one of their top three priorities in this regard, but few have taken the time to measure the level of digital maturity their organization has achieved. A company’s digital quotient (DQ) is a function of how well defined its long-term digital strategy is, its effectiveness in implementing that strategy, and the strength of its organizational infrastructure and information technologies. The companies that incorporate the notion of DQ into their short list of performance metrics can more effectively monitor their progress across the digital capabilities we’ve outlined here, enabling more targeted investments and accelerated rates of digital growth.

Indeed, the companies that ultimately succeed in omnichannel marketing and sales will likely resemble tech companies and, interestingly, publishers—effectively using big data and digital touchpoints to drive growth and reduce costs, while producing and managing a variety of content (catalogs, coupons, web pages, mobile apps, and user-generated content) in real time across multiple platforms to create breakthrough customer experiences. This means rethinking the analytics that inform their segmentation strategies, the flow of the experiences they design, and the way they set up their internal operations for faster iteration and delivery of service.

About the authors

Edwin van Bommel is a principal in McKinsey’s Amsterdam office, David Edelman is a principal in the Boston office, and Kelly Ungerman is a principal in the Dallas office. They are leaders in McKinsey’s revenue enhancement through digital (RED) initiative, which redesigns the consumer decision journey to encompass all commercial levers, across all channels and touchpoints, thereby creating growth in revenue and profits.

The Hospital of the Future is not a Hospital

Great insights into where capital is being invested in US healthcare…

http://www.healthleadersmedia.com/print/LED-305089/The-Hospital-of-the-Future-is-Not-a-Hospital

The Hospital of the Future is Not a Hospital

Philip Betbeze, for HealthLeaders Media , May 30, 2014

Pursuing expensive inpatient volume in the traditional sense is a strategic dead end. Any new construction undertaken by hospitals and health systems should be based on adaptability, patient flow, and efficiency gains—not bed count.

I’ve spent a good deal of time the past several weeks interviewing senior healthcare leaders for my story in the May issue of HealthLeaders magazine about the hospital of the future. But in truth, that headline might be a bit of a tease.

As it turns out, the hospital of the future doesn’t look much like a hospital at all. Instead, it’s a cohesive amalgamation of plenty of outpatient modalities that represent growth in healthcare. Inpatient care, increasingly, represents stagnation and shrinkage, in the business sense.

In the past, a story about the hospital of the future has meant investigating healthcare organizations’ access to capital, and their ability to fund expensive new patient bed towers with all-private rooms and top technologies, in a race to grab volume from competitors.

Under that operating scenario, the sky was the limit, in terms of what organizations were willing to do to attract volume.

That calculus has changed drastically.

In a recent survey on healthcare design trends conducted by Minneapolis-based Mortenson Construction, 95% of the healthcare organizations surveyed said most of the projects they are undertaking are predominantly ambulatory in nature.

“If, in theory, the [Patient Protection and Affordable Care Act] has now got 7 million people engaged in healthcare insurance who didn’t have that previously, the inrush of patients will be outpatient-based,” says Larry Arndt, general manager of healthcare in the company’s Chicago offices. “What’s not needed is bed space or heavy procedural space.”

A Strategic Dead End
The PPACA, employers, and commercial health plans have made clear that pursuing expensive inpatient volume in the traditional sense is a strategic dead end. That doesn’t mean new patient towers won’t go up, but it does mean their construction will be based on adaptability, patient flow, and efficiency gains, not bed count.

As few as five to seven years ago, says Arndt, a healthcare leadership team would take a capital improvement project through a planning and programming phase in which they followed a traditional approach. The team would utilize widely standardized metrics and program their building based on what they’re doing now, with no consideration of the future, Arndt says.

By contrast, within the last five years, more leaders have been embracing the concept of lean operational improvement.

In order to be competitive in a limited amount of reimbursements, they have had to become more efficient. So instead of the traditional approach of programming new construction based on how the organization operates today, instead, it attempts to map out its current patient flows and discover how to become more efficient. Only then will the team look at how to build around that improved and more efficient model.

Indeed, a whopping 22% of respondents to Mortenson’s February survey said they were “doing nothing” construction-related right now, and only 5% were planning for a traditional replacement hospital.

Instead, a majority said they are focusing new construction on building clinics that can feature just about any outpatient modality except surgery, Arndt says.

Healthcare Shifts to Outside
They’re focusing on combining dialysis, radiology and other treatments that can be provided in one location. And they’re funneling more of their capital budget to items that are outside the realm of new construction, like home health and what Arndt calls e-home healthcare—in other words, technological solutions that help patients access their caregivers outside of any facility.

“Our customer understands that healthcare is moving more toward healthcare outside a facility,” says Arndt. “That means more money is being invested in health information technology. Also, you see more constellation or satellite projects, for example, a small 15,000-20,000 square-foot clinic in a neighborhood. That allows patients to travel a shorter distance to a less congested environment, but yet allows connection to the bigger facility if needed.”

Modular construction is a trend that Arndt sees developing quickly. It’s in the process of designing a clinic for a client that will feature modular walls, to make it more flexible for the changes in care protocols that are assured, but that healthcare’s leaders aren’t sure how will ultimately affect their competitive offerings.

In one clinic, doctors want to be able to meet with patients in groups, for example. Modular walls mean physicians can occasionally meet with groups of patients instead of individually, or vice-versa. Their space is less limiting.

“The clinic can adapt,” says Arndt.

Prefabricating buildings is also gaining steam in healthcare, he says.

“Money is being invested much more wisely than it has been in the past,” he says. “For the design/construction field, we have to be more lean too.”

Part of that lean attitude means offering customers 3-D modeling that starts with design partners, such as the people who will be staffing the building, to optimize work flow.

Adapting Takes Time
“We can prefab things we couldn’t years ago,” he says. An example might be a bathroom “pod” that can be built offsite and installed on site. Full exam rooms can be prepared the same way, and models can be constructed to test care protocols with the team that will be working there.

Arndt’s customers, he says, can be categorized two ways. Either they’re thinking broadly about adapting to the future without knowing exactly what it’s going to bring, or they’re standing idly on the sideline until they understand better how the PPACA and other drastic changes in how healthcare is provided and paid for will affect their bottom lines.

Neither approach is necessarily better than the other, but waiting just puts off the action that needs to be taken. It can be a prudent approach, but even in healthcare, what works can change quickly. Designing, building, and adapting still takes time.

Don’t wait too long.


Philip Betbeze is senior leadership editor with HealthLeaders Media. 

Esther Dyson on the population health rampage!

 

http://www.healthleadersmedia.com/print/TEC-303509/Esther-Dyson-Launches-Population-Health-Challenge

Esther Dyson Launches Population Health Challenge

Scott Mace, for HealthLeaders Media , April 15, 2014

A tech investor with a proven track record of attracting innovation and money to a variety of endeavors is looking for a few good communities to compete for the greatest improvement in five measures of health and economic vitality.

Wellville

Healthcare ladies and gentlemen, start your communities.

That was the call on April 10 from angel investor and tech advisor Esther Dyson, whose population health dream has taken a big step toward reality with the launch of the Way to Wellvillecompetition.

From now until May 23, Dyson’s nonprofit startup, HICCup, is inviting communities to apply to be one of five contestants in a five-year-long competition to get healthy using everything from the latest fitness gadgets to reality TV. Dyson is HICCup’s founder and chairman of EDventure Holdings.

The 20-page application form is not for the casual applicant. Individuals or consultants need not apply – we’re talking community health organizations, other nonprofits or perhaps the local Better Business Bureau.


Esther Dyson’s Population Health Dream


Why bother? Several reasons. Dyson is an early investor in all sorts of innovative startups, with a proven track record of attracting innovation and money to a variety of endeavors over the past 25 years. She also is a great listener, having convened various listening sessions around the country last fall to get this latest idea off the ground.

Dyson’s fledgling organization, HICCup, found its footing in those sessions, and also a CEO, Rick Brush, who spent nearly a decade at Cigna, where he was chief strategy and marketing officer for the national employer segment and launched the payer’s Communities of Health venture.

Esther Dyson

Esther Dyson
Photo: courtesy of Joi on Flickr.

At one of those early scoping sessions, Brush asked the kinds of tough questions about what Way to Wellville should be measuring that landed the answers in HICCup’s FAQ and himself in the CEO’s chair, Dyson tells me.

A ‘Learning Lab for Health’
“What we’re trying to do is almost create a learning lab for health with subsidiary projects and contests along with the five-year marathon,” Dyson says.

Back to that lengthy application, which goes beyond asking about a community’s healthcare, straight to the health of a community, seeking such metrics as percentage of temporary residents, household income, poverty levels, and a slew of outcomes data – percentages of a community with diabetes, heart disease, asthma, smoking status, obesity and more.

Applicants also have to describe their top previous successes and failures trying to improve community health, healthcare financing innovations such as ACOs, patient-centered medical homes, population health, bundled payments, and so on.

In other words, it’s a lot of the things that HealthLeaders readers are currently embarking on both individually and collectively. And if the prestige of being selected for the first-of-its-kind national competition of sorts doesn’t intrigue you, there are a couple of other things to consider.

First is the cash prize at the end of the five years. HICCup itself won’t be rewarding such a prize, but hopes to raise $5 million for it. “Honestly, contestants are going to have to spend $15 to $50 million as a community to do this, so you’re not doing this for the prize, though of course it matters to some extent,” Dyson says.

Second, and more importantly, Way to Wellville contestants will become part of a larger community amongst the five competing communities. They will meet face-to-face in September at an annual conference, Next Step to Wellville, about a month after the five competing communities are selected.

The actual judging of who wins in 2019 has yet to be decided, but it will be a third party for legal and fiduciary reasons. Dyson emphasizes that the organization doesn’t have all the answers yet.

Metrics Matter
If you believe, like I do, that healthcare is closer than ever to some tectonic shakeups courtesy of technology, then Way to Wellville is likely to be a great observation post. Innovative medical hardware and software companies are already flocking to a variety of competitions such as this. Way to Wellville is just taking a bigger view of what kind of population health solutions will ultimately be necessary.

Expect also a lot of intermediate measurements and competitions.

“We’re hoping that some of these quantified self vendors will come in and donate devices to the communities and so we’ll have Fitbit and Fuelband contests,” Dyson says. “[Add to that] the county health rankings and all of these sorts of official measures, most of which are a year or two old, and we’re all going to get a lot more real-time data.”

“You can’t report transitions to diabetes every month,” Dyson says, “so there will be some health measures that are kind of yearly, but then there are, the outcomes measures tend to be slow. The input measures, like the percentage of school lunches that contain no French fries or something, you can measure in more real time.”

The $15 to $50 million table stakes per community sounds daunting to me. “It’s not the community goes and gets a $50 million grant from somebody,” Dyson says. “It’s more than they get a $10 million grant for, let’s say, heart health. There’s a $2 million program for food subsidies for fruits and vegetables. There are accountable care organizations that find an investor to improve the health so that their costs go down. There are social impact bonds.”

Philanthropists Wanted
“So it’s a combination of a large number of different kinds of funding from donors, from social investors, from vendors giving in-kind services or goods, and maybe in outer years, the school board raises a bond to do something with the school lunch. Each community is going to need to get money and support from a variety of courses in a variety of funds.

“We’ll be looking for people who want to invest in various ways of producing health. We’re also looking for donors [and] philanthropists.”

And of course, Dyson is reaching out to her famous set of angel investor friends. The goal, of course, is to go beyond that. Another way to maintain excitement on Dyson’s agenda is “a cheesy reality TV show” and perhaps a documentary.

As we see more and more crowdfunded efforts springing up in healthcare technology, Dyson’s approach has some similarities – with perhaps a crowd with deeper pockets, or at least one that’s been around the startup block a time or two.

Dyson hopes for up to 50 applicants for the five spots, and already has solid interest from several communities. Her population health dream is alive, and by this fall we should start to see some manifestations of it.


Scott Mace is senior technology editor at HealthLeaders Media. 

Russian bank rewards customer exercise…

Now we’re talking… very Russian, no mucking around… even if it was developed by an ad agency. Go team…

http://www.springwise.com/russian-bank-rewards-customers-sweat-higher-interest-rates/

There are countless initiatives designed to get the public fitter and healthier, but (perhaps unsurprisingly), it’s often those that offer a financial incentive that prove the most effective. We’ve already seen gym classes which become cheaper the more the user works out, and Nike’s Facebook app which enables runners to pay for products with kilometers they have run. Taking the link between financial savings and health benefits to an even more literal level, we’ve now come across a Russian bank offering a new account which rewards customers for every step they take.

To take advantage of Alfa-Bank’s fitness account, and it’s high interest rate of 6% per annum, users first need to sync their Jawbone, RunKeeper or Fitbit fitness tracker to the bank. Then, using the new Activity™ software, the user decides how much their activity is worth. They can select for every step or meter they walk or run to transfer between 1 to 50 cents into the fitness savings account to enjoy the high interest rate. In essence, the more the user walks, sweats, and exercises, the more they’ll save. The video below shows the initiative in action:

Created with Moscow-based advertising agency and marketing consultancy 42 Agency, the idea is already proving a hit with beta testers. How else could banks take a greater role in their customers’ lives for the better?

Website: www.activity.alfabank.ru/Activity/
Contact: activity@alfabank.ru