Tag Archives: Healthcare

Ridiculous Healthcare Pricing

All over the country people are commenting on the ridiculous pricing from healthcare facilities and providers.  Here is a recent example I came across:

Lab Bill

You’ll note that the gross price for these lab tests is $837.74 and the person was told their out-of-pocket responsibility could be $109.85.  What is so amazing about this is I have heard of wellness companies that purchased lab services for their programs being charged $21 for a similar series, without the PSA, if the draw was done at a laboratory service center and $65 if the draws were done onsite at the employer.

So lets take out the PSA at $148.48/$19.47 and there you have it, gross pricing for these services is almost 33 times what they sell this service to wellness vendors on a wholesale basis (which obviously has a profit in it), and the person getting these tests could potentially pay four times that amount out of pocket with their PSA portion excluded.

I assume that the insurer, a major health plan, has a larger discount than that given to a wellness vendor. It will be interesting to follow this and see if the health plan pays any portion and what the final out-of-pocket is for the person. If it totals $21 I’ll eat my hat.

The markups in healthcare, which are driven by FFS pricing and payers who sell to employers based upon discounts off of charges has created a monster that is completely dissociated from reality.



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Running to the Ball: the Shiny Object of Social Determinants of Health

Social Determinants of Health (SDoH) are all the rage, we see it discussed by hospitals, physicians, IT companies, health plans, academia, community non-profits, government, and the list goes on and on.  It’s amazing how rapidly addressing SDoH has sprung up as “the solution”, and it may in fact be.  But before we get too excited we need to consider that approaches to solve SDoH need to be operationalized and who does what, how the approaches are overseen, and accountability will make or break the outcomes.

The current behavior of the majority of sectors reminds me of a kid’s soccer game.  If Soccer Kidsyou’ve ever watched one you’ve no doubt seen a mass of children tightly arranged around the ball, each one trying to kick it, while 98% of the field is wide open.

Effective teams spread out, each one playing their role, in their assigned space while being held accountable.

If we’re not careful, our current efforts to address the Social Determinants of Health in each of our communities will experience the same thing, a promising approach will be replaced by the next healthcare shiny object; not because the concept was wrong, but because the execution was flawed.

So how should these efforts be organized, who should be in charge and who should be Walking Dogaccountable for what?  Here’s an interesting photo to ponder as an example, it’s used quite often in presentations about obesity, behavior change and in just a few instances, Social Determinants of Health.

Audience –  “Ha ha, that’s the lazy American, just look at them driving and walking the dog, they are the source of our obesity problem. We need behavior change. They need to get out of that car and walk.”

And in response to the clamor, in rushes our current healthcare system “get out of our way, we have come to solve the obesity problem, we are going to do it by addressing the new-fangled shiny object, Social Determinants of Health.”

And the overall system say’s “fine, let’s hold the hospitals and doctors accountable for the obesity problem by establishing quality measures and value-based reimbursement and penalize them when their patients are overweight, or our health measures don’t improve.”

And run towards the problem we all go.

But, perhaps the healthcare system shouldn’t run in so fast or forcefully to the ball, perhaps the healthcare system shouldn’t be the one to kick it at all.

A better response might be “Wait are you/we sure?  Can we really fix this? I don’t see any sidewalks? Is the neighborhood safe?” Or the myriad of other issues associated with Social Determinants of Health.

As Bones, Doctor McCoy might say, “ Dammit Jim, I’m a Doctor, not a sidewalk builder, Bonesengineer, grocer, community non-profit, housing authority or police officer.”

And if it’s not the healthcare system that can solve these problems, perhaps, someone else should lead these effort’s, resulting in the healthcare system focusing on their unique and needed areas of expertise.  Playing their role on the field as a team member.

To solve the SDoH, the most critical role the healthcare system should be addressing is the oft forgotten Triple Aim concept of “lowering the costs of healthcare”.   It’s estimated that 30% or maybe more of healthcare is waste, unnecessary, fraud etc.,  that’s a meager trillion dollars that we could and need to free up to provide funds to the groups building the sidewalks, opening grocery stores, creating safe neighborhoods, improving education and the rest of the issues we know so well.  Addressing the SDoH should not require new funds, the money is there already, it just needs to be released.

And when it comes to focus and accountability, I’m not just picking on the healthcare system. Those in government, non-profits, IT etc., need to play a role, by working in their unique space, on the field.  And in that role, they too need to be held accountable.  Just as the healthcare system has waste that needs to be freed up or eliminated, many community organizations and government players have been working for years in their communities yet the statistics on health status are no better or getting worse.  What benefit has the community gotten from those services? And in the  IT world many companies have promised interoperability, increased efficiency, improved outcomes, yet we still haven’t seen it. Unfortunately, the list of poorly executed systems crosses all players.

It’s time to organize a broad-based coalition, not led by the healthcare system, but led by the community with the healthcare system at the table (and not the biggest vote either), each sector bringing their expertise, playing their position and being held accountable.  If we all run to kick the ball, try to be the coach, go after that shiny object called Social Determinants of Health, we’ll end up right where we are; just older, having squandered another goal scoring opportunity.



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The Triple Aim, Well Two Out of Three… Really is Bad

One of the Triple Aim‘s has gotten lost. Will anyone in the healthcare sector publicly declare that they are in fact working on the Double Aim?

The Triple Aim, that lofty set of goals that the healthcare system claims to have embraced:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and.
  • Reducing the per capita cost of health care.

I agree with them and believe they are appropriate and necessary.

Everyone it seems, says they are working towards the Triple Aim, and many have taken to adding Provider Satisfaction and saying we in fact need a Quadruple Aim. Well, before we go there, let’s see what we are actually doing on the initial three.

After attending a number of conferences and seeing what the system is in fact doing,  I’m fairly certain, that healthcare is not actually going after the Triple Aim. In fact, it appears that almost everyone has quietly agreed on the “Double Aim” in an effort to short-circuit any true progress and continue on the path we have been on.

What do I mean by the Double Aim? Here are some examples of things I saw, heard or didn’t hear at HIMSS 2018:

After listening to an excellent panel on innovation, by three leading health system executives who oversee their systems innovation area or department, I just had to ask a question:

“At what point does this innovation actually lower costs?” A murmur arose in the room.

Response one:

“Well we could spend a whole day on that one”

The next answer? Well, there wasn’t one.

At the conclusion of the session, Gregg Masters spoke with one of the panelists and asked if as part of their innovation center they were tasked with lowering costs.  Their response “no, that’s not part of our charge.”

Why wouldn’t an innovation center also be looking for innovation that reduces costs?

At a dinner panel one evening, a health plan association executive when asked if health plans were really lowering costs, pointed to the Medical Loss Ratio (MLR) Rule (which I have written about here) as a key contributor to holding costs down.  When I explained my belief that the MLR rule ensures costs go up because “who would want 15% of a lower number next year” there were audible chuckles of agreement in the room, a shocked look on the panelists face and the panel quickly switched to another topic. While the person who asked the original cost question, looked at me, raised his eyebrows and laughed.

I do not recall any booth or individual discussing programs that save money, in fact most were talking about revenue enhancement.

Only Kaveh Safavi of Accenture and one other presentation discussed the elephant in the room; that healthcare is the only industry where as it adds technology, the workforce gets less efficient.  I would call the behavior we exhibit in this regard, an addiction.  We continue to do it, even though the outcomes will be bad for us.

Do we not hear the clamor associated with the Amazon, Berkshire-Hathaway, JP Morgan?

“Healthcare is the Tapeworm of the American economy”


Or the announcement by Wal-Mart regarding their narrow network, in which they said that about 40% of people referred to their center of excellence for back surgery were told they don’t need it. How about the growing relevance of Dave Chase and the Health Rosetta and books like Dan Munro’s Casino Healthcare, or the Health Value Awards.

Even the esteemed Dr. David Nash of the Jefferson College of Population Health saying there are too many medical errors and too many tests being ordered and it was “time for doctors to look in the mirror”.  But not just doctors, all sectors of healthcare, especially hospital systems, health plans, device and pharmaceutical manufacturers and vendors. You may be thinking you can slip by with the Double Aim, but others are AIMing to knock the inappropriate costs out of the system, and if you don’t get involved it might be you.

And now when CMS announces their Pathways to Success, a new ACO requirement that pushes ACOs which have been living off of one-sided risk in the MSSP program, and showing no savings, to two-sided risk, the industry goes bonkers.


We know there are excesses in the system, everyone talks about that, everyone talks about the Triple Aim, but it seems in the case of doing things versus talking about the Triple Aim, we are truly only interested in the Double Aim.


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Where is the Elon Musk of Healthcare?

In April of this year I presented at the University of Mississippi Center , School of FG spacex,-moonshotsanddiabetesPopulation Health. A description of that presentation is on LinkedIn:

SpaceX, Moonshots and Diabetes in Mississippi


Musk Falcon Heavy Cut

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PopHealth Week Now Available on iTunes

You can now download all of the episodes of PopHealth Week on iTunes. Future episodes will be added as they are recorded.  Please have a listen, subscribe and rate the show.

Here is the link:


PopHealth Week on iTunes


PopHealth Week is a production of Health Innovation Media.



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