Business of BPM

Healthcare Blog

I have decided to split out into two separate blogs.  Probably not easier on myself, but I think it represents my two areas of work right now.  With that, I have started The Patient Advocate blog which is more about healthcare and consumerism.

It includes some of the historical posts from here, but my intent is to manage the two separately.  Here I will talk about process related issues and technology while I focus on healthcare over there. 

You Have to See Sicko

Have you seen Sicko?  I got the management team from a healthcare client of mine to go see it with me last week in Boston.  I thought it was great.  If you know nothing about healthcare, you will think our system is the worse system in the world and be appalled.  If you work in healthcare, you realize Michael found and did a great job of pointing out many of the weaknesses. 

He also did a good job of identifying some interesting facts and showing us how healthcare works abroad.   Without being a spoiler, here are some observations:

• People without health insurance that get hurt face some very tough challenges.  We need some type of care system that supports them.
• Our  processes should not interfere with care.  Dropping people off in hospital gowns  since they can't pay their hospital bills is wrong.
• Drugs are a lot cheaper outside the US.
• The hypothesis that you wait for care outside the US seems to be a myth.
• Running a company based on denial of care versus managing risk through wellness is a problem.  This ties to bigger problems we have with the system design.

Before I go off as a liberal republican (or conservative democrat), my only recommendation is see the movie. 

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Medical Devices and the 10 Faces of Innovation

Today, I unsuccessfully searched for a smart consumer device that would link process and medical monitoring.  I am sure it is out there, but I couldn't find it.  The opportunities are numerous. 

Imagine having a device that monitored your blood sugar levels and sent off messages based on your current levels.  The messages could be to home to make something different for dinner.  It could be a note to yourself to remember to snack earlier in the day.  It could be a note to your physician keeping them aware of your situation.  I think that the opportunities for consumer centric medical devices that have embedded intelligence and plug into some type of BPM or process centric model are great.

This made me think of one of my favorite companies - IDEO.  If you don't know them, you should.  They have been involved in all types of innovation and product design.  The Art of Innovation by Tom Kelley is a great book about their process.  You should also read the article about the different types of innovators in Fast Company. 

This article categorizes them into Learning, Organizing, and Building personas.  Which are you?  I am either a Cross-Pollinator or a Collaborator (in my mind anyways).

CDHC - Success or Failure

It is probably too early to make any decisions here around Consumer Driven Healthcare (CDHC), but I enjoyed an entry on Matt Winn's blog Punctuative about this (see entry).  A quote I especially like is:

If I were a product manager in any other industry and saw scores this low in customer satisfaction and understanding, I’d be thinking of pulling that product from the shelves or retooling it,” says David Guilmette, managing director of Towers Perrin’s health-care consulting practice.

I believe a big issue here is communications.  Patients suffer from too many healthcare communications and too much healthcare information which is delivered to them in ineffective mediums (e.g., letters that happen two weeks (or more) after the event) using confusing language and ask them to jump through hoops.  CDHC (and healthcare in general) will be much more successful when companies embrace a CPG (consumer packaged goods) approach to driving behavior.  I am working with a client right now that has had some great successes in this area and which has some great idea.  It is worth your time to look at them if you operate in this space as an HR director, a managed care company, a pharmacy benefit manager, or even a healthcare provider.  The company is Silverlink.

Wellness Incentives

Last year, I had a chance to do some consulting for my previous employer (Express Scripts).  One of the areas that I helped them with was CDHC (consumer driven healthcare).  I worked on competitive intelligence, framing the opportunity, and creating the strategy pitch including evaluating a technology investment.  Recently, I have ended up in a few conversations about this topic so I thought I would spend a minute on it.

Incenting people to get serious about health and wellness is an interesting challenge.  You have a handful of questions to answer:

1. What behaviors do you want to encourage?
2. How can you shift behavior?  (And who are you - employer, insurance company, disease management, marketing company?)  This has to take into account messaging, channel, timing, value proposition, demographics, etc.
3. Is there a return for your money?
4. Will consumers allow you to step in in a big brother type role to tell them what to do?

There are some interesting players out there.  I was always fascinated when I saw that Humana (who is progressive in many things) was working with Virgin to offer airline points for working out at a gym (for example).

Now, there are several companies focusing specifically on creating wellness incentives (IncentiveLogic, Hallmark Insights, Healthpoints).  There is even a Wellness Council of America.  I found an article on their site that provides a good overview - click here.

Some related information:

• 2001 article on wellness at work
• AON article on creating an effective wellness strategy
• Elizabeth Boehm who is a good Forrester analyst has an article about this
• A story about a specific company example and results
• National Wellness Institute
• Horizon BCBS points program
• Humana's Virgin LifeCare
• Lots of the managed care companies are offering health discounts (e.g., BCBS VT)

I could go on.  It is an interesting topic.  As the focus grows, you will see your consumer experts begin to focus on this problem.  It is not unlike the move from defined retirement to 401K.  With CDHC and other programs, the consumer is becoming more important in making healthcare decisions.  With that, an understanding of the health consumer is important.  This is not done well at most companies today especially with any of the typical marketing rigor that you would expect - segmentation models, campaign management, database analytics, etc. 

   

Value Based Insurance Design

Now here is a name written by either an academic or someone from finance - "value based insurance design".  Try selling this to the masses.  But, regardless of the name, the concept is very interesting.  At the core, most of what I have seen revolves around companies (e.g., Marriott) reducing the copayments on certain drugs for patients that are compliant with other actions (i.e., taking other medications, participating in disease management programs).  I had provided clients with some advice on these programs 2-3 years ago before it had a name.  Now, we even have an Center for Value Based Insurance Design at my alma mater - University of Michigan.

The key challenge here is plan design and how to create incentives that motivate people to take the right actions.  Here are some of the questions that I remember struggling with a few years back:

1. Do you reduce the price of all drugs (or some drugs or just generics) for patients that comply with recommended actions?  How much is meaningful?  If you make them free, does that change their perception of the costs and value of prescription drugs?
2. What type of patient profile (e.g., tenure, age) will this work for?
3. How do you track compliance?  Just because they register doesn't mean they comply?
4. How does this tie back in to broader health initiatives?  Are there other incentives that aren't prescription based?
5. How do you get this information into the hands of the patient in a timely fashion?

A lot of these questions play into the broader field of CDHC (consumer driven healthcare). 

If you are interested in this topic, you should visit the Center and Activehealth.  Activehealth was acquired by Aetna and is clearly the leader in this space.

So...linking this back to BPM is pretty easy.  VBID takes a process (which is the patient's healthcare) and establishes a series of rules (e.g., if they do X, lower their copayments on Y).  They systems need to connect a series of companies / databases to share information (think SOA).  Subsequently, the company investing in this type of solution needs a dashboard and reporting to understand their results and how their investment is paying off.  Finally (and ideally), the company needs to have some ability to do simulation and understand how changes to the rules might impact future results.   

Healthcare Appeal Process

Healthcare is such an easy target for BPM opportunities.  I am living one right now. 

In December, we had to refill a prescription for my son.  It happened to be 2 days before Christmas.  Since I had switched insurance carriers, Aetna now required a PA (Prior Authorization) for the drug (although my son had been on it for a year).  By the time, I got the message and tried to call the physician, he (a specialist) was gone until the new year. 

I had to fill the prescription and pay cash since I needed my son to stay on the drug.  So, in January, I downloaded the appeal form; completed it; had the pharmacist complete it; and mailed it in.  In March, I heard back from Aetna that it was rejected.  Fortunately, after working in the industry, I know that you can appeal it multiple times, and I understand the coding and reject process.  After talking with a call center agent, I had them change some of the notes on the claim to reflect the situation with my physician and appealed it a second time.

It is now May, and I got a letter telling me they haven't finalized the review process but have received my appeal.  I should know something in 60 days. 

This has to be easier.  All parties have to be frustrated.  The Aetna PBM has to spend expensive pharmacist time reviewing these multiple appeals; answering multiple calls by me; and sending me multiple letters.  My employer and Aetna will eventually have to pay a claim from 2006.  I am out the cash and spending valuable time trying to work the process.  And, none of us have much if any visibility into the number of appeals, the average cycle time, the status, and how to change this process.

BPM could help with this in many ways including simply streamlining the process. 

eRx with BPM?

From a pharmacy perspective in healthcare, one of the more elusive solutions has been e-prescribing (or eRx).  There are numerous companies (e.g., Allscripts, Prematics, Purkinje, RxNT, Zixcorp, iScribe) that have solutions and many more that have died over the years.  When I was at Express Scripts, we funded RxHub which was an industry solution by the PBMs (Pharmacy Benefit Management companies) to facilitate eligibility checks and other electronic transactions.

The goal of e-prescribing is to eliminate safety errors associated with wrong prescriptions, drug-drug interactions, non-compliance, and many other issues.  Anyone who has ever seen a doctor's hand written prescription can understand.  Here is an example from the Prematics site:

Some of the managed care companies have spent millions rolling out these solutions.  In general, most of them are adopted as interesting tools and then disgarded by MDs at the first sign of trouble.  Honestly, there is very little in it for them unless they have a quality bonus. 

Physicians are one step removed from the filling of the Rx.  They care about patient safety, but it is hard to change their working habits. 

So, I wondered the other day whether BPM could solve the problem.  Doctors all use some type of system for managing their office.  This ranges from simple systems that just capture data to much more involved PPMS (Physician Practice Management Systems) or EMR (Electronic Medical Record) systems. 

Could a BPMS use a process to:

1. Push data from the physician's desktop using messaging queues;
2. Run the data through some eligibility and adjudication logic;
3. Identify issues real-time; and
4. Then either route it back to the MD for questions or send it to the patient's pharmacy of choice.

An interesting spin on this would be to do an auction at the end where pharmacies could bid on the prescription (e.g., BidForRx).  Patients could create customized rules in the BPMS solution that processes the claims and managed the auction based on their interests.

Just a thought.  This seems to make adoption easier (no change in process); deployment cheaper (no ongoing support); integration cheaper and easier; and add additional value (patient involvement). 

Healthcare Examples

Here is a message I pulled together for the HC CIO...

Have you seen the improvements and ways that Business Process Management (BPM) is being used in the Healthcare industry?  BPM is one of the latest approaches in continuous improvement that blends technology with process.  Rather than focus on total reengineering, BPM improves the efficiencies of your current or streamlined processes and helps you leverage your existing assets.  Given the staffing constraints across healthcare and other industries, this can give you an opportunity to grow your company without adding staff. 

Some examples:

1. Veteran’s Health Administration is using BPM to improve their benefit eligibility process focusing initially on income verification.

2. Gaston

   Memorial

   Hospital

   is using BPM to reduce the time to post job openings internally and has gotten it from days to seven minutes.  Gaston has also started using BPM for patient incident reporting and approval of new medical forms.
3. Lee Memorial Health System used BPM to cut their recruiting time by 50% and reduce new employee record creation from 9 hours to 10 minutes.
4. A 500-bed hospital is using BPM to manage their dietary management system reducing errors while assuring continued accreditation and improving patient, family, and physician satisfaction. 
5. A payer is using BPM to streamline their appeals and grievance process to improve accuracy, consistency, and timely resolution.
6. Another payer is using BPM to increase the efficiency of their call center allowing them to increase membership by 48% without an increase in staff.
7. Another payer is using BPM to manage their provider credentialing process from application capture through case resolution.

Some other examples of how BPM could be used include creation of a virtual EHR, accounts receivable, coordination of benefits, capturing process level metrics, contracting, procurement, product management, and project management.

BPM can help you increase quality while lowering the cost of care and provide a technical, rules-based solution for managing processes and their exceptions.  Additionally, given your historical investments in disparate systems, BPM serves as an abstraction layer that overrides your existing architecture so that changes can be made on an ongoing basis with massive development efforts and many implementations are made within 90-days from process mapping to production.   

Creating the automated coach

A typical struggle that a large company has is how to deal with mid-market companies or average customers.  Typically national clients or repeat customers get great attention, but it is hard to give this same customized attention to an average customer even if they might be your next big customer.

This challenge is exasperated by the difference between your average customer service or account management professionals and your top performers.  How do you embed the DNA of the top performers in that of the average employee.

When I was at Express Scripts, I used to half-kiddingly suggest creating an "automated pharmacist".  All of our clients from individual groups of 200 people to the Department of Defense with 9M members all wanted a pharmacist to provide them with personalized recommendations based on their member demographics and triggered by market events - e.g., Prilosec goes OTC (over-the-counter), Zocor loses patent, a new drug comes to market.  There was no easy way to do this.

Additionally, all of us who use the healthcare system want more personalized attention from our physicians, nurses, pharmacists, physical therapists, etc.  But, of course, we don't want to pay a retainer to have them on call.  We just want them to somehow manage to give us proactive advice.

Any professional services firm (e.g., accountants, lawyers) has this same challenge.  When something changes (e.g., long-distance excise tax), how and when do they communicate this change to all of their clients and help them assess the impact of this change on their business. 

Companies with distributors or retail branches have similar challenges from communicating downstream or upstream changes across the different constituents to help them prepare in advance.  For example, if your advertising company calls and tells you the ad copy will be 2 days late which means the collateral will be printed 3 days late which means that the supermarkets installing your new display have to shift schedules to have it set up 4 days later...

Well...it didn't hit me until this morning, but Business Process Management (BPM) technology could help here.  We could map these processes til the cows come home, but that won't do any good.  Streamlining these processes, capturing the rules, embedding logic into the process, codifying best practices, and integrating these human and system centric solutions can create this automated intelligence.  It is not artificial intelligence but it can help manage your clients and create real personalized value.

Let's stick with the pharmacy example:

• Image that Claritin announces it is going over-the-counter
• This trigger from the Pink Sheets kicks off an internal process
• The process queries the claims database to identify the number of patients with Claritin claims
• The internal process sends an e-mail to all the account teams within your PBM (pharmacy benefit manager - e.g., Express Scripts, Medco, Pharmacare, Caremark, Argus) or MCO (managed care company - e.g., Aetna, Cigna, Wellpoint, BCBS)
• Based on rules or election by the account teams a subsequent e-mail is sent to each of the clients
• The client can opt-in to a communication to their members
• This approval triggers a mail merge of a pre-approved letter which is sent to all the affected members (patients)

This is a service that every client wants.  They want the hand holding, but it is hard for large companies to give this to every client.  There is not time enough to have all these discussions, talk about customizing the letters, wait on customer approvals, or manage things through e-mail when people are busy and unavailable.  A BPM approach to this embeds the logic and creates a personalized flow triggered off key events that can initiate dormant processes that are waiting in the background.