In the Age of Health Reform, Healthcare IT to the Rescue?


Talking about health insurance is a good way to clear a room. It is a rare person who is excited to interact with their insurance company or who can understand the explanation of benefits they receive in the mail detailing all of the things that the insurance carrier has decided not to pay on their behalf. According to JD Power and Associates, only four out of ten people fully understand their health benefit plan. No doubt those four are also able to read the Dead Sea Scrolls in their original text.

JD Power also found that consumers rank health insurers at 710 on a 1000-point scale, a number heading downhill faster than Lindsey Vonn. In contrast, consumers rank homeowners insurance carriers at 750 on a 1000-point scale and auto insurers at 837. Nothing like being last place in the league: just ask the Minnesota Twins.

“So what am I supposed to do about it?” you might say. “My employer gives me whatever insurance they want to give me and I have little say in it.” We as consumers have become accustomed to paying (through paycheck deductions and lower wages) for a service we dislike but over which we have little control and even less affection.

Well that world is about to change—maybe not for everyone, but for many. Whereas our selection of what health insurance plan to use has been more like picking which monopolistic cable company to connect with, the advent of healthcare reform, and especially the provisions of the Patient Protection and Affordable Care Act (PPACA) that go into effect in 2014, may well put the consumer in the driver’s seat. In fact, Psilos Group, the healthcare investment firm to which I pledge my allegiance, believes that healthcare reform will have a much greater impact on businesses and consumers than originally predicted, accelerating a sweeping change among health insurers toward consumer-oriented business models and totally different distribution channels, partnerships, and technology solutions. We released a 2011 Healthcare Outlook Report earlier this week that details the expected changes and illuminates the key issues that face the healthcare industry as PPACA becomes reality. You can access the full Psilos Group report for free by clicking here.

One of most significant changes in the health insurance realm will be that more and more Americans—including millions of corporate employees as well as the previously uninsured—will begin shopping for their own health insurance via a new landscape of Internet and call center-based public and private healthcare insurance exchanges. These will function as shopping hubs to connect individual consumers with a choice of insurance products, supported by a broad network of insurance brokers who serve as agents to the consumer. The result is expected to be a doubling or tripling of the market for individual insurance today from about 10 percent to between 20 to 40 percent of the commercial market in coming years, according to industry experts such as McKinsey & Company.

Given this backdrop, health insurers will have to shift their approach from a traditional business-to-business sale to a business-to-consumer model to garner a share of this new market. Like other consumer-oriented companies, health insurers will need to differentiate their offerings based on cost, quality, customization, and service. To survive this paradigm shift and introduce the operational efficiencies essential to avoiding the fate of Blockbuster in a Netflix world, health insurance leaders are going to need to make a quantum leap forward in the use of technology to transform their businesses.

Healthcare and information technology were rarely uttered in the same sentence 10 years ago, unless eye-rolling was involved. While all of the large insurance carriers have a plethora of information systems within their walls, they historically have not been viewed as … Next Page »

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Lisa Suennen is a managing director with GE Ventures and former managing member of the Psilos Group, as well as the co-author of Tech Tonics: Can Passionate Entrepreneurs Heal Healthcare With Technology? and author of the blog Venture Valkyrie. Follow @venturevalkyrie

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6 responses to “In the Age of Health Reform, Healthcare IT to the Rescue?”

  1. Health IT will make a lot information system work better and make us smarter but we are reaching a certain saturation point with how much doctors can learn and about the investments of insurance companies in the data aggregation side who want to be in the consultant arena where the big bucks are now to make data communicate. If this does not work, it’s the next bubble as hospitals are having hard financial times and CIOS are burning out.

    Something is going to have to give…stressed CIOs..

    Also experts still miss the boat on how to engage consumers with gluts of software nobody uses or wants, they just write it because they can so innovation without collaboration is fouling up the US healthcare system.

  2. Lisa –

    Your article was both cleverly written and insightful. I look forward to reading through the full outlook report you made available.

    There is certainly growing momentum behind consumer directed health options…a trend that started a decade ago with the first concierge practices, HSAs, groups like Carol etc…perhaps we’ll see increasing momentum when PPACA kicks in. I am not immediately bullish on the free flow of data, more efficient medical banking etc given that there are deeply entrenched issues and groups like the Medical Banking Institute (now part of HIMSS) have been working to facilitate innovation in this space for years. Will the pressure on insurers central to reform force the issue downstream in a positive way? I am hopeful, but highly skeptical. Lots of churn is still in the cards.

    I am also hesitant to place any certainty about where the ACO model will ultimately end up given a long history of dead models (ex. RHIOS) that had similar life-cycles and objectives and died on the “good intention” grape-vine. Obviously there is movement in the space, but hitting a trifecta at Santa Anita Racetrack is a safer bet.

    As for providers, you point out a very interesting metric around hospital re-admissions. The well-worn stat that gets tossed around far too much in the industry is 100K unnecessary deaths per year. When you review the data underlying that number, it’s a very difficult number to affect, and its probably inflated to begin with. However, readmissions, as you point out, is a costly problem and one that has a myriad of areas poised for improvement and some nice wins ahead.

    That said, we work with providers nationwide in all practice settings and see their EHR and overall technology adoption first-hand on a daily basis. While they are eager to embrace technology that will provide demonstrable ROI, many of the systems on the market are legacy pigs upon which lipstick is being generously applied. Moreover, many of these systems, like the institutions that purchase them when applicable, may talk open standards, web services, free love etc etc…but the political and data silos are still real and still have to be addressed before serious innovation and solid business models can evolve out of the data.

    At a macro level, the coming decade of healthcare IT is going to look like the wild wild west. The large IT orgs will have to innovate at least in part through M&A. The Internet revolution that influenced the banking,supply chain and consumer markets over the past decade is poised to have a major influence on healthcare. There is a positive mix of willpower, capital, political support and increasingly innovative thinking. There will still be lots of well intended efforts that line the roads with their dead carcasses, but we’ll likely see some really solid wins to keep everyone excited enough to get out of bed and go after it again tomorrow.

  3. Hi Tobin, thanks for the note. I think your skepticism on some of the current healthcare IT initiatives is warranted. The industry is going to have to embrace technology as a means to an end rather than accept it because someone else is paying or because they have no choice. While there is tremendous promise in the ACO initiative and also with the widespread adoption of data fluidity, there are many cultural issues that make the outcome in the short term very hard to estimate. The good news is that lots of very well-intentioned and smart people are out there trying and innovating. I think that the realities of the financial marketplace will tell the tale of the tape. If carriers’ and providers’ businesses can’t compete because they haven’t committed to technological advancement, they will probably learn the hard way.

  4. Barbara, I really agree with you about the consumer data issue. Very few of the applications out there are meaningful enough to consumers to use them as regular tools and the lack of integration with their core data makes most of them weak as tools of overall health improvement. Whoever really cracks this code will make a big difference. Lisa