Media coverage of Amazon/Berkshire/JPMorgan misses the point.

The coverage of the JPMorgan/Amazon/Berkshire Hathaway healthcare initiative has been universal, breathless, and mostly superficial.

Scoffers, “experts” are gleefully predicting this attempt to do something really different will fail miserably, victim of ignorance and hubris. While there are no guarantees, these naysayers ignore:

  • the three CEOS and their staff are brilliant, powerful, have almost unlimited resources, and are very, very cognizant of the difficulties they face. These are as far from idealistic newbies as one could get.
  • the “competition” is pretty lousy, hasn’t delivered, and their incentives are NOT aligned with employers’. If the big healthplan companies could have figured this out on their own, you wouldn’t be reading this.  It’s not like A/B/J are taking on Apple, Salesforce, or the old GE.
  • the financial incentives are overwhelming; healthcare costs are over $24,000 per family and heading inexorably higher. Unless these companies reduce and reverse this trend, they’ll have a lot less cash for future investments.

Many are also talking about “initiatives” that are little more than tweaks around the edges; things like:

  • publishing prices and outcomes for specific providers aka “transparency”
    My view – research clearly demonstrates consumers don’t pay attention to this information, so there’s no point
  • using technology to monitor health conditions and prompt treatment/compliance
    My view – lots of other companies are already doing this, and this is by no means transformational
  • use buying power to negotiate prices
    My view – it’s about a lot more than price, it’s about value.

Here’s a few things A/B/J may end up doing.

  1. Own their own healthcare delivery assets.
    My view – Insourcing primary care, tying it all together with technology, and owning a centralized best-of-breed tertiary care delivery center would allow for vastly better care, lower patient hassle, and cost control.
  2. Buy healthcare on the basis of employee productivity
    My view – Healthcare is perhaps the only purchase organizations make where there is no consideration of value – of what they get for their dollars. To the Bezos’, Dimons, and Buffets of the world, this is nonsensical at best. They will push for value-based care, defined as employee productivity.
  3. Build their own generic drug manufacturer
    My view – No-brainer.
  4. Allow employees to go to any primary care provider they want, but require them to go to Centers of Excellence for treatment of conditions that are high cost with high outcome variability.
    My view – No brainer.

I’d also expect many more large employers will join the coalition, for the simple reason that they have no other choice.

What does this mean for you?

Do not discount this.


Disruption of the US “healthcare” “system” is starting

Today’s announcement that Amazon, Berkshire Hathaway, and JPMorganChase are forming a new entity to deliver health benefits to their workers may well be the harbinger of massive change to come.

credit Collaborative Lab, Rachel Botsman

While many details are to be determined, the new company will be:

“free from profit-making incentives and constraints” and

“The initial focus of the new company will be on technology solutions that will provide U.S. employees and their families with simplified, high-quality and transparent healthcare at a reasonable cost,”

Here’s what I see as key factors.

  • These three giants have intimate knowledge of health insurers and healthcare providers. The biggest takeaway is they have determined insurers and providers are not performing today, and will not perform tomorrow. 
  • Amazon is a delivery machine – and knows way more about us than we do. The company knows logistics better than any other entity; it is also a world leader in analytics and “behavioral understanding.” Add in the Echo, and it’s current presence in and knowledge of tens of millions of American homes is a huge asset.
  • JPMorgan Chase is a financial empire that deeply understands investments, financial drivers, banking and fund flows. It has massive capital – $2.5 trillion in assets – a giant consumer banking enterprise, and brilliant people.
  • Berkshire Hathaway is huge, diverse, enormously well regarded, and very well run. BH brings perhaps unmatched management capability to the partnership, as well as multiple insurance assets staffed by people who understand risk.

Notably, stock prices for healthplan giants UnitedHealthcare, Anthem, and Aetna – and others are down 5 percent this morning, with analysts crediting the announcement for the damage.

It’s critically important to note that the companies that have dominated the healthplan industry for decades are, in the view of three dominant firms, not performing. In fact, their performance is poor enough that the three CEOs all noted they don’t have all the answers, the implication being they believe they can do a better job than the supposed experts.

The release is here.


Telemedicine – where next?

MCM’s Telemedicine Week continues with a couple more use cases and a quick summary of where things are going – with the caveat that we’re only just beginning to understand what this is, how it can be used, what the obstacles and limitations are, and how accelerating technological changes will affect tele-…

First up, CHC’s white paper authored by colleague Peter Rousmaniere. CHC has a broad suite of tools used for everything from recorded statements to triage to initial clinical “visits”. The case study discussions provide a glimpse into the future, as there’s a lot of crossover between and among the use cases.

HSA consulting client MedRisk launched it’s telerehab program last year, and takeup has been strong. To date, patient reaction is quite positive, driven in large part by high satisfaction from one-on-one interaction between the patient and therapist. The white paper provides a detailed review of everything from technology to applications; a wealth of references are cited for those interested in more detail.

From here, where?

  • Wearable technology has yet to be incorporated into services, but I expect it will be soon. Devices that track range of motion, force, and acceleration will be used to monitor home exercise and help assess patient readiness to return to work.
  • Other devices will assist in diagnosis and patient monitoring, alerting both patient and clinician to potential problems or conditions that may affect recovery or determine treatment paths.
  • Peer reviews can be improved by virtual visits, enabling the peer review physician to interact with the patient without the expense and hassle of meeting in person.


  • Represented patients may be loathe to schedule tele-visits if their attorneys don’t understand or support tele-services.
  • Regulations are going to be playing catch-up for the foreseeable future. Issues related to reimbursement, admissibility, liability, confidentiality and the like will take time to work through.
  • Change aversion will be the highest and toughest barrier. We all know workers’ comp can be hidebound and kludgy, with participants looking for “reasons why not rather than opportunities to.”

All that said, the more we learn about tele-services, the clearer it is that this is going to be a major change driver.

What does this mean for you?

Get with it.



Telemedicine – Concentra’s approach

Today we’re continuing to dig into what individual companies are doing in telemedicine.

Quick take is there are about as many offerings and approaches as there are companies; it’s good to see the breadth and depth of thinking, the various business models, and how different stakeholders view challenges, benefits, risks, and future trends.

Today brings an update on Concentra’s efforts (I interviewed CEO Keith Newton last summer, here’s the second of that two-part post).

Concentra was an early adopter of telemedicine; the company’s physician base, integrated information and practice management systems, and employer- and insurer-relationships and IT connections gave it a big head start.  There was also a compelling business reason; not all physicians were busy all the time, so Concentra had a ready supply of credentialed providers available for telemedicine visits.

The company recently logged its 600th virtual visit, a big jump after hitting 400 in mid-December. Things started slowly with launch mid-2017, but I’d expect a fairly rapid ramp-up after months of preparation and “beta-testing.”

I spoke with CEO Keith Newton and Ann Schnure, VP Telemedicine Operations about recent developments and future plans; Ann also provided written answers to emailed questions. (some answers edited for brevity, also some para-phrasing of responses)

  1. MCM – What tele-services is Concentra currently offering?

Briefly, telemedicine in the form of virtual visits for injured workers. Concentra’s telemedicine product, Concentra TelemedTM, was designed specifically for workers compensation and the treatment of injured workers. Patients can access virtual care from a Concentra occupational medicine clinician using their computer, tablet or smartphone. Concentra Telemed leverages the same clinical model, EHR system, and reporting used in our medical centers.

In February, Concentra will launch a telerehab product leveraging the Concentra Telemed platform. Eligible patients requiring physical therapy will be offered the option of a scheduled telerehab visit with a licensed Concentra therapist.

  1. MCM – How has adoption of telemedicine progressed?

As we expected, adoption of telemedicine in work comp has been gradual.  As telemedicine in work comp is in its early stages of adoption…(Note the average Concentra patient has 2.1 – 2.3 telemedicine “visits”, all post-triage.)

  1. MCM – What’s been the biggest challenge to getting employers to use TM?

The key challenge to overcome is the knowledge gap about how to apply and integrate telemedicine into their existing work practices. Much of our work with employers has been to inform them how Concentra Telemed easily fits into their existing processes and workflows. Their current processes to authorize treatment, service instructions, and back-end reporting remain the same regardless of whether they use telemedicine or brick-and-mortar clinics.

  1. MCM – What’s been the biggest challenge to getting patients to use TM?

The primary challenge to getting patients to use telemedicine is creating awareness. Many patients simply do not know a telemedicine option is available for the treatment of their work injury. Knowing that over two-thirds of consumers are willing to see a clinician via video, we are confident that with increased awareness the willingness to use telemedicine for work injuries will increase over time.

Once patients become aware and try Concentra Telemed, we know they consider a video visit the preferred option. Over 98% of Concentra Telemed patients choose telemedicine when they require a follow-up visit.

  1. MCM – Talk about the regulatory environment.

There is growing acceptance of telemedicine as an important health care delivery channel by medical boards and government regulatory agencies. While telemedicine is now allowed in all 50 states, regulation specific to work comp has been slow to materialize. Additionally, some states have yet to modernize regulations to accommodate telemedicine. When developing and launching telemedicine in work comp, we feel it is a state-by-state approach which requires working closely with work comp agencies.

  1. MCM – What metrics is Concentra using to evaluate its tele-services?

Our metrics for telemedicine are the same metrics we use to at our medical centers. These include measures on case duration, return to work, and key clinical outcomes.

The patient experience is also critically important to us. Patients who use Concentra Telemed are asked to rate their experience with our product at the end of each visit. Patients provide an average satisfaction rating of 4.8 stars (out of 5), with 85% of patients rating their visit with 5 stars.

  1. MCM – What will Concentra be doing with tele-services in 2019?

By 2019, we envision Concentra Telemed being a coast-to-coast solution embraced by employers and accepted by regulators as a valuable option for the treatment of work injuries. We’re evaluating over 14 potential use cases leveraging the Concentra Telemed platform, including travel health, center rechecks, and specialty services.


Telemedicine – Coventry’s approach

A few weeks ago I had the opportunity to virtually sit down with Coventry’s product development folks to hear what they’ve been doing with tele-. 

I checked in again this week, and here’s what they’ve been up to. Quick take – tele-triage is gaining traction, while patients are slower to agree to do virtual office visits.

Coventry, a provider of services ranging from networks to pharmacy benefit management, case management to durable medical equipment, is well into Phase One, of their telemedicine offering which is tied into Coventry’s Nurse Triage program, NT24.

Working with technology vendor KuraMD  Coventry’s nurse triage staff connects with the patient, evaluates the injury or illness, and, based on their findings, recommends an appropriate level of care whether it be self-care, a “live” visit with a clinician, or a telemedicine visit (urgent and emergent cases are identified at call onset). Diagnosis and other factors drive the recommendation.

While the program has been in place for the better part of a year, Coventry has found many customers have yet to embrace the telemedicine office visit. Customers have “a tough time thinking of this as an office visit.” Telemedicine providers provide initial visits where they can send patients to physical locations for physical therapy or for imaging studies. While TM follow-up visits are offered, to date most employers want patients to visit a provider for those follow-up visits.

The program is live with two TPAs; a total of 10 employers have been implemented to date nationally with 4 in single states. Employers are quite diverse, including labor, retail, temp staffing, and construction.

For those patients able and willing to use telemedicine for a virtual initial visit, Coventry uses providers contracted with KuraMD. Care coordinators initiate the tele-visit, ensuring the patient has the right technology, walking the patient through the set-up and sign-on process, then passing the patient to the clinician for the visit.

Concentra will also be working with Coventry in the future

Phase Two involves broadening the number of clinicians that can provide telemedicine and also offering telemedicine visits without the nurse triage component. As one of, if not the largest workers’ comp PPOs, Coventry is working to get information to the company’s contracted network physicians to educate them about the service and requirements, discuss compensation, and provide training. The credentialing process and standards are identical to the company’s “regular” network but there are more questions regarding state licensing to ensure compliance with state regulations.

Down the road, Coventry is looking to incorporate tele- into case management. Ideally, case managers would connect with the patient, provider, and/or employer via video conference and enter information in real-time into the company’s proprietary CM IT system. There’s much work to be done connecting with claims systems to identify the types of and format of information needed by adjusters, build data feeds, and separate out key bits of data that need an adjuster’s attention.

What does this mean for you?

Expect tele-visits to gain traction as patients use similar services for family members and their own care. Telemedicine is moving quickly in group health, and this will accelerate adoption in comp.



In the 30+ years I’ve been around the workers’ comp industry, there hasn’t been anything truly disruptive, until now.

Telemedicine, telerehab, teletriage are just three of the ways technology will enable remote delivery of services to injured workers and other key participants in the injury recovery process.

The implications are broad and deep, as are the challenges.

The implications are robust; Faster access to care. Quicker determination of compensability, causation, and relatedness.  Deeper understanding of psycho-social factors. Stronger rapport with employer and patient. Instant access to information for adjusters and case managers. Better tracking of patient compliance with physical therapy and home exercise.

The challenges are many: Do patients and providers have the necessary technology. Are connections secure. Do laws and rules allow for/support/enable tele-everything. How and who will get paid how much for what. What jobs are at stake. How will service providers adapt to tele-everything, and can they.

And this isn’t touching the implications implicit in the adoption and use of Artificial Intelligence, which will revolutionize most of what is done in our industry.

We’ll focus on tele-everything this week, with interviews with several of the early adopters.



What’s going on with health coverage for poor kids?

The current clustermess in DC around keeping the government funded is just bizarre.

What’s most bizarre is politicians are holding poor kids hostage, which is the only way to describe what is happening.

Republicans are refusing to consider legislation – requested by the President – to address DACA as part of the budget resolution. This is a core requirement for many Democrats, as is long-term funding for CHIP.

Background – CHIP has long been a bi-partisan program, championed by Sen Orrin Hatch R UT among other staunch conservatives. It provides insurance for poor kids and pregnant women, and has been funded for decades with nary a blip. Till now.  CHIP has been unfunded since October; most states are about to run out of residual funds, which would throw about 8 million poor kids and pregnant women off the program – and leave them with no insurance. 

This makes no sense.  If the Childrens’ Health Insurance Program is re-authorized for a decade, it SAVES $6 billion.  There is NO fiscal reason to NOT re-authorize CHIP, just a political one. The GOP is using the re-authorization in an attempt to force Democrats to support a budget proposal that is anathema to many Democrats – and more than a few Republicans as well.

It appears likely that we’ll be forced into a government shutdown over this, which will end up costing taxpayers a LOT more money than if the party in power had just passed a budget months ago as it was supposed to.  In case you aren’t as nerdy as your author, there have been four separate continuing resolutions to keep the government funding since Trump was inaugurated – and there are NO plans by the Senate Appropriations Committee to discuss a budget for this year – or next for that matter.

Moreover, the Committee, which is dominated by Republicans hasn’t even bothered to hold a vote on a budget over the last year.

If this stuff makes you nuts, well, it should.

What does this mean for you?

Be very thankful you aren’t a poor kid.  And really mad about what this idiots are doing to poor kids. 

Ring in the New year with the latest and greatest…

Blog posts!

Health Wonk Review returns to the inter-webs after a holiday hiatus. Refreshed, renewed, and revitalized, we bring you the best from the brightest!

Drug costs 

Typically, we think that drug co-payments as affecting patient payments.  However, cost sharing can also affect the price drug companies charge for their goods.  The Healthcare Economist examines a case study in Germany to see how changes in cost sharing have affected drug prices.  

Adam Fein’s entry reveals a scary new cost shift; “plan sponsors—employers and health plans—will save big money because accumulators shift a majority of drug costs to patients and manufacturers.” 

ACA and related matters

Enrollment figures are almost final, and no one has a better grasp on the data than Charles Gaba.  HealthCare.Gov ended up exactly 5% behind last year( which in turn was 5.3% short of the previous year) State enrollments were also about 5 points lower. Considering the shortened deadline, lack of outreach/advertising and so on, this is actually pretty damned good all things considered.

From HealthAffairs blog, a post discussing how state-based strategies may help protect against the instability that the federal mandate repeal could introduce to health insurance markets.

Louise Norris looks at the impact of the Affordable Care Act’s medical loss ratio provision and explains how the “80/20 Rule” works, noting that it’s forced health carriers to devote more premium dollars to care and required them to send more than $3.24 billion in rebates to plan members when they haven’t.

We’ve got another timely post from Louise on the potential impact of expanded association health plans, including a summary of the current regulations and how they could change with expanded AHPs:

The impact will vary depending on what type of coverage people have now, but there are certainly concerns that the ACA-compliant individual or small group markets could face adverse selection in some areas of the country if AHPs expand significantly. There are also concerns that people might switch to AHP coverage and then find out that the coverage isn’t as good. 

InsureBlog’s Patrick Paule explains why the ACA’s Health Insurance Tax keeps bumping up insurance prices, including employer plans and even Medicare Advantage plans.

Workers’ Comp

At Workers‘ Comp Insider, Julie Ferguson takes a look back and a look ahead at the workers comp landscape in a substantial wrap-up of news that shaped the prior year and trends that we can expect in the year ahead.

The Pump Handle’s entry dives into a new report by the National Academies, noting that the occupational health surveillance systems in place today “have generally not evolved to address the changing nature of work.” The authors refer to non-standard work arrangements, such as through temp agencies, “on-demand” or the “gig” economy to make their point.

Interesting posts you can’t find anywhere else

In David Williams’ podcast, Vericred CEO Mike Levin describes the company’s role as a clearinghouse for health plan information on provider networks, benefit design, rates and drug formularies. 

Roy Poses has long been discussing how corruption – particularly of top health care leadership – causes health care dysfunction.  Yet now there is good evidence that the top level of US government, the presidency, has been corrupted.  A Sunlight Foundation webpage catalogs hundreds of instances of conflicts of interest and corruption affecting the president and his family.   So far, there have been no congressional investigations of this corruption, much less congressional action to combat it.  Dr Poses asks “how can we challenge health care corruption under a corrupt regime?  I now submit that doing so first requires excising the corruption at the heart of American government.”

My contribution is a brief descriptor of the change I see coming in the US health care “system”, change that will be massive, disruptive, and desperately needed.



WCRI is just around the corner

Had a chance to sit down with WCRI CEO John Ruser a couple weeks ago and get his take on the Institute’s Annual Meeting, scheduled for March 22-23.

For those who have yet to attend WCRI, get yourself there this year…and unlike other conferences, attendance is limited.

I’d strongly encourage you to register now if you haven’t already…

MCM – What’s going to be different about this year’s conference?

JR – We are going to start with a focus on the future – Dr. Erica L. Groshen, former Commissioner of Labor Statistics and head of the U.S. Bureau of Labor Statistics will open with a discussion of the changing workforce and technology’s influence from the perspective of a labor economist, more about what is going to happen.  The theme throughout the conference is we will revisit that.  The Sedgwick Institute’s Dr. Rick Victor (former WCRI CEO) will speak to the challenges facing work comp system including the changes in the workforce, We will close with a panel discussion to hear from different perspectives on this theme.

MCM – Why this focus?

JR – There’s been an acceleration in the rate of change in the workforce, we thought it was time to bring that topic into the conference and bring it to bear on workers’ compensation in particular, it’s time to start considering this in our conference. I anticipate there will be discussion of potential impact of these changes on claim frequency and claim severity.

MCM – Any teasers you can provide on what those trends might look like?

JR – In general, what’s going on in the economy in the labor market is the substitution of capital for labor; capital we used to think of as heavy machines, now it’s software and computers are driving the trend where high risk jobs will go away because of substitution of capital for labor.

Since I’m an optimist and this has been happening for 150 years or so, I believe new jobs will spring up, the question is what does that mean for workers’ comp. Along with that is the change in the employment relationship typified in part by Uber, but its gong to be amore general aspect of the labor market where workers won’t necessarily be attached to employers in the way they were before. That certainly creates challenges for workers’ compensation.

MCM – The implication is that insuring occupationally related injuries and illnesses is going to fundamentally change, is that fair?

JR – It certainly will change.  We’ve seen a quarter-century of declines in OSHA reportables and claiming rates, there is a notion the workforce is changing so there aren’t as many claims as there were in the past.

MCM – There is some indication that wages are heading up in some states, but given the substitution of capital for labor, that means folks in low wage jobs are not going to see increases in pay. For that and other reasons is it likely we will see medical expenses continue to increase as a percentage of claims?

JR – This is the area that Dr Groshen is going to get into…There are other factors as well, new technology that will help workers recover faster or even survive accidents that they wouldn’t have before. With that comes higher medical costs. Advanced prosthetics allow injured workers to function better, and while costs will go down over time, for now those devices are quite expensive.

MCM – Is there going to be discussion about Artificial Intelligence and the role that is going to play?

JR – Yes, that is likely to come up. There are lots of other topics, for example are we ready for value-based care? We are doing work interviewing stakeholders to determine if we are ready for that, and that will be a discussion topic at the conference. We have a session on opioids and the impact of opioids on return to work. The National Safety Council and a large employer will talk about the issue of opioids in the workplace.

Fee schedules, prices, and access to care is always a topic of interest. We will be looking at this, in particular comparing group health to workers’ compensation in several areas including delays in accessing primary care and other types of treatment.

The agenda is here.

2019’s conference will be in Phoenix…

So much for the “Opioid Crisis”

A 24-year old is acting as chief of staff of the Office of National Drug Control Policy.

Of course he has no experience, qualifications, or background that qualifies him for this role. And, ts ONDCP has no Director or Chief of Staff, this kid has been one of, if not the, senior executives at the federal agency tasked with addressing the opioid crisis.

Taylor Weyeneth, who happens to be from our town, also submitted a resume to the federal government that exaggerated his “credentials” (he claimed a graduate degree he does not have).

According to newspaper reports, he was involved with a “family company” here that federal records show was “secretly processing illegal steroids from China as part of a conspiracy involving people from Virginia, California and elsewhere.” Weyeneth’s resume claims he was head of production for this company when he was 16.

Weyeneth is the symptom, the Administration’s complete lack of attention to the opioid crisis is the problem.

This personnel debacle follows the Administration’s attempt to appoint Tom Marino as Director of ONDCP. Marino is a politician that sponsored a bill greatly limiting federal oversight of the opioid industry. an attempt that fortunately collapsed amidst bi-partisan outrage.

Seven Administration appointees have left the Office over the last year; that’s more than 10 percent turnover in the 65 person office. There is no Director in place, and no indication there are any plans to appoint one.

The President gives speeches about the crisis, and claims the Administration is doing everything possible to attack the drug crisis – and Taylor Weyeneth is appointed Deputy Chief of Staff.

Words are one thing, actions another.

What does this mean for you?

We aren’t going to get any help from the White House on opioids.