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Insurance and Pricing as Gateways to Changing the Health Experience

Posted on March 31, 2015 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site ( and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

“So why are you partnering with insurers and employers?” I asked the staff at Maxwell Health, who had just been regaling me with an expansive vision of consumer-centered health and transparency. Co-Founder and Chief Product Officer Vinay Gidwaney laid out a view that’s in line with everything reformers ask for: a long-range view of health care that guides people to proper health at home and not just in the clinic, giving the consumers choices along with the information to let them make good ones, etc. The kind of health system Maxwell Health aims at will be totally different from what we have now–and the current actors will have to change or vanish as it comes into being.

Maxwell Health on phones

Maxwell Health running on phones

But of course I knew why Maxwell Health is dealing with insurers and employers. In our health care system, you must join the guild to hang your street sign. Before you can get access to the consumer, you need access to the professional organizations with whom the health consumer interacts. Individuals may download one or two of the many thousands of available health and fitness apps, but few people stick with them–or with the fitness devices that carve their behavior into eternal records in the cloud.

Although doctors complain that they can’t change people’s behavior, people are more likely to adopt technology if it is recommended by their doctor, their insurer, or even the government. Furthermore, payment models have to reward the right things, or people will continue to engage in risky behaviors and costs will continue to expand.

So Maxwell Health has found a business model on the insurance side of health care’s multi-faceted polygon. Through this they hope to reach the consumer and create change.

Another company I met at the Health 2.0 Boston hackathon, a week after talking to Maxwell Health, is making a related play in order to prosper in the health care market. PokitDok offers health care appointments on both a pay-per-visit basis and using health insurance. To this end, they have relationships with both health care providers and insurers. They can be used by any individual consumer, whereas Maxwell Health deals with people through their employers. A PokitDok API allows developers to create apps that have access to prices, providers, insurers, referrals, etc.

PokitDok screen

Getting started with PokitDok

Let’s start with Maxwell Health. Their salient feature is “bundles” of health care options offered as benefits packages by employers, organized around a core of the insurance plans their staff can choose from. Maxwell Health can direct an employee to an appealing insurance package–for instance, one for people near retirement, another for a young couple about to have a baby. Benefits administrators create personas (hypothetical types of employee) around demographics such as age, income, and family status, then create bundles to offer to employees around these differences. Anyone who has tried to seriously compare his insurance options knows what a headache it is to figure them out. Medicare Advantage is a daunting market, and while no employer has such a large number of choices, they have enough to make the decision a nail-biter. I had trouble just choosing my tax-free flexible spending amounts each year, until the law changed this year and let employees roll unspent money forward. Maxwell Health hopes to turn benefit choices into an experience as appealing, well-integrated, easy as a good online retail shop.

While choosing an insurance plan, employees are prompted also to sign up for services that may help them with their health needs: fitness devices, coaching services, emergency day care, meal delivery services, etc. Bundles also contain services that benefits coordinators think would interest employees with a given persona.

The customer can also load apps from Maxwell Health that help them find services. For instance, they have a contract with Doctor on Demand, a popular telemedicine site. (This one-time telemedicine service is a convenience, not a replacement for developing a relationship with a provider who has a broad knowledge of the consumer and family.) Another service lets employees can take a picture of a confusing medical bill and contact an expert to explain and even change the bill.

On the back end, Maxwell Health provides typical web-based services to benefits administrators, making it easier for them to carry out their routine tasks such as determining participation in plans by employees and tracking the use of services. As PR and marketing associate Meg Murphy says, benefits administrators “can throw away their fax machine.”

The company’s solution requires a lot of work at each employer, but the insurance broker is well positioned to work with each employer to represent the benefits correctly, suggest new benefits, and serve up the benefits through the Web and mobile devices. In addition to its close work with insurers, Maxwell Health also lets fitness devices stream data to a Maxwell Health mobile app. This app has three overall parts: a virtual insurance ID card for every insurance plan in which the employee is enrolled, a wellness program with connections to fitness devices and rewards, and a healthcare concierge who handle requests like the confusing bill already mentioned.

Now for PokitDok. The simplest part of their offering is an app helping consumers find doctors for individual fee-for-service procedures. A consumer can search for the medical procedure he needs and book an appointment through the service. PokitDok determines fees through a rather labor-intensive process (calling the doctors) as well as by checking actual prices paid in the past. The web site guides the user by showing a range of possible insurance costs (low, median, and high).

Once the user chooses a provider and books a procedure, PokitDok charges the posted fee and collects the money online. Hence, the welter of health care costs is managed by simply making each provider advertise his fee (already quite a break from the standard health market in the US.) PokitDok therefore includes a degree of transparency for its providers that Clear Health Costs provides through crowdsourcing for a wide range of popular tests and procedures.

But PokitDok also allows patients to pay through insurance. This is a much steeper challenge. Insurance reimbursements vary from doctor to doctor, plan to plan, and employer to employer. Nor do most of the actors in this masquerade want to reveal their prices and the yawning ranges they span. So PokitDok, once again, checks prices paid in the past to estimate the low, median, and high cost for insurance coverage. The user can also specify one or more insurers when searching for a procedure.

It’s interesting that John Riney, coder and technical evangelist at PokitDok, described their essential goal in terms very similar to those used by Maxwell Health representatives: let’s turn the search for health care into a consumer experience as simple and satisfying as good retail shopping.

Right now, the main actors in the health care space maintain silos. The new players like Maxwell Health and PokitDok feel the way most of us in the health movement feel: they would prefer an open ecosystem where the parts work together and anybody can sign up to play. Piggybacking on a complex payment system set up decades ago may be the necessary focal point on which new companies can press the lever of change.

A Practice’s View of ICD-10

Posted on January 16, 2013 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

In our recent article about AMA’s call to Halt ICD-10, we got a really interesting practice perspective on ICD-10 that I thought I’d share. The comments come from Sue Ann Jantz who works at a medical practice. Sue brings up some really interesting points that I think are on the minds of many practices and doctors. The final one about 3rd party payer systems is an important one.

In your recent article
The American Medical Association’s most recent call to halt implementation of ICD-10 codes brings to light an interesting angle to the coding story – one that I hadn’t recognized until I read up on just why the AMA has consistently made it known that the switch is a bad idea.

My two cent’s worth:
See, all of the coding changes are going to fall on the physicians — they won’t be able to pawn it off on anyone else, like a nurse or a coder/biller or an administrator. Remember, they do MEDICINE, not transcription, billing, personnel or business.

This is especially true of docs in large organizations such as hospitals and multispecialty clinics (MSC), who believe they have to do all the extra preventative care things because the government tells them to — not realizing that the incentive payment has some administrator licking their chops. As far as most Admins are concerned, getting the docs to do extra work doesn’t cost the hospital or MSC anything, so, why not?

Add to that the perfect storm that’s brewing: HITECH act —> electronic records and meaningful use (MU), ACA —> ACOs and reconfiguration of alliances, and then ICD-10 —-> total rearrangment of charting/documenting (plus the unknown).

And you are surprised there’s smoke coming out of the AMA’s ears? Personally, I am concerned there will be meltdown in the medical community. As far as most of them are concerned, this is all Obama’s fault, and they are furious and busy telling everyone who comes in that Obama is the devil. Granted, those that blame Obama are the one I’ve heard — so that’s probably a limited group in Kansas.

At a coding seminar recently, the presenter asked how many were going to get out before ICD-10 kicked in. Most of the room of 50 people raised their hands – about 80 percent. Further, they said their physicians were going to retire before that happened as well. ICD-10 is slated to go into effect Oct. 1, 2014. Everyone is supposed to be signed up for health insurance by Dec. 31, 2014, bringing anywhere from 15 million to 30 million people into the health care system looking for a provider.

Do you think this might be a problem?

That said, individually, all three of these things are long overdue. Had each been done when they needed to happen, we wouldn’t be in this fix now. Plus, ICD-10 will go into effect and a few months later, ICD-11 will be implemented everywhere else in the world — some think we should skip to ICD-11 … but we probably have enough on our plates at the moment.

Politically, Sebelius has to get this done before the end of Obama’s term. I hope it doesn’t crash us. I am working on it all as if it’s all going to happen. We are not part of an ACO, we probably won’t get to MU1 even though we are working on it because there isn’t enough money in it, although we did do the Adopt/Implement/Upgrade part of the HITECH act. So, that only leaves ICD-10. and I am working on our templates, those instruments of the devil by Sebelius’ standards. Without templates, we wouldn’t have a prayer.

And none of this addresses the 3rd party payer systems … which will probably crash if the early tests are indicative. That means we will not get paid. So I am stockpiling money for that time now.