Entrepreneurs' Outlook for the Healthcare Cloud Is ... Cloudy

I’ve written sunny posts about the opportunity for entrepreneurs in key areas of digital healthcare: health & fitness wearables and healthcare transparency businesses. The “healthcare cloud” is a third major area of innovation, but here the opportunities for entrepreneurs will be fewer and will carry more risk. [Disclosure: New Atlantic Ventures in which I am a partner has an investment in one of the four companies cited below: TruVeris.]

First, the pro’s: the idea of putting data and applications in the cloud is taking hold throughout the IT world, including healthcare. Payers and providers get the fact that they are being held accountable for managing cost and outcomes for groups of people (“Population Management”) and they are working hard to master this problem, which creates strong need to collect and analyze data from many sources in one logical database. And cloud technologies promise to both lower costs by strengthening care coordination, and to improve clinical outcomes, e.g., analysis of medical data in the cloud has revealed drug interactions that were not previously understood (1)

Problem 1: It Will Take A Long Time To Get Results From Healthcare Cloud

Healthcare has a culture of holding data close, particularly among payers, which are mostly insurance companies that make money by understanding risk better than customers and competitors. Data is the basis for understanding risk. HIPAA, the law that protects healthcare data privacy, was enacted before the cloud era and gives data holders the perfect excuse to not share. And there is the problem of incompatible legacy systems and data formats: healthcare IT did not grow up on open standards like the Internet did. At a forum for entrepreneurs, Jonathon Bush, the CEO of AthenaHealth, declared passionately: “It stinks [paraphrase] to be a healthcare entrepreneur … because you can’t get your hands on the data.”

And, once you have the data, using it is not straightforward. For example, a business that wants to use cloud-based meta-analysis of medical data to guide drug development is ultimately limited by the FDA’s commitment to tried and true double-blind trials as the gold standard for drug approvals.

Problem 2: The Healthcare Data Incumbents Are Powerful, And Not Asleep

The drive to “accountable care” is causing healthcare providers to consolidate, usually around a strong regional hospital system. Hospitals are buying up doctors’ practices and now employ over 50% of doctors. Strong regional payers (e.g., the Blue Cross/Blue Shields) create provider networks as part of their business, and those networks will become “narrower” (less choice, so the same providers are always working together) in response to cost pressures. So the most relevant cloud for a provider is the cloud used by the hospital system that employs him or the narrow network of which she is part. Hospital systems already have an electronic medical record (EMR) system in 90% of cases, and the payers already have their system that captures diagnoses and treatment events, and manages payment. These are the two most important databases to be integrated into the cloud healthcare cloud.

It’s likely that these powerful incumbents will create clouds for their systems/networks, and if a few players cooperate they can create a regional cloud. This will be the relevant cloud for most of the providers and payers in the region, and both healthcare services and health insurance are primarily regional businesses. An open, national cloud that entrepreneurs can tap to create new value is probably not the first step.

And, there is a set of strong healthcare software companies, some with significant cloud services business, that aim to build a healthcare cloud. They include companies like Cerner CERN -1.32% (hospital EMR leader), AllScripts (e-prescription leader), and AthenaHealth (cloud-based billing services, not long ago a disruptive start-up). These companies have relationships with many of the healthcare players and they hold part of the data set that belongs in the cloud.

Problem 3: The Big IT Infrastructure Companies Are Diving Into The Cloud, Too

Cloud services are heavily based on infrastructure and platform: data storage, communication, and horizontal applications like databases and security. Scale matters in these businesses, and they are dominated by the likes of Google GOOG -1.02%, Oracle, Amazon, IBM, and Microsoft. Their services are generic and may lack specific features like the proper audit trails for HIPAA compliance. And sometimes they miss an opportunity, as they did with the folder-sync-and-backup model that Drop Box and Box.net have built up. But, they are well capable of building healthcare specific features on top of their platforms, and well aware of the business opportunity. Healthcare has been a big vertical market for IT companies since the beginning.

So healthcare entrepreneurs will be sailing on rough seas, starved for data nourishment, and beset by killer whales.

Tim Draper once told me: “Great entrepreneurs don’t know what can’t be done.” They always surprise with their creativity and tenacity finding value and bypassing obstacles. Examples of companies making a go of it in the healthcare cloud include both healthcare-specialized cloud infrastructure companies …

• TrueVault: cloud-based database-as-a-service that complies with healthcare regulations

• ClearDATA: cloud-based storage (one level lower in the stack than TrueVault, similar to Amazon S3) that meets healthcare regulatory requirements

As well as companies offering specialized applications that utilize healthcare data from multiple sources …

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Sandy Wright, left, 
gets help from Jessica Haynes, 
a certified nursing assistant, in Peoria, Ill.
CreditJim Young/Reuters

UNLIKE other areas of health care, the cost of hiring someone to help tend to an aging family member at home has been relatively stable.

You’ll now pay a median rate of $19 per hour for a hired homemaker, who does household tasks like cooking and cleaning, according to the latest report on the cost of care from Genworth Financial, which sells long-term care insurance. You’ll pay a bit more, about $20 per hour, for a home health aide, who helps with personal care like dressing and bathing but not medical care.

The cost of home caregiving has gone up only about 1 percent annually over the last five years, compared with an increase of about 4 percent a year for institutional care, the report said. The report reflects the cost of hiring a home caregiver through an agency, which typically costs more than directly hiring a caregiver.

The difference is partly because home care providers don’t have to maintain large facilities and generally have fewer regulations to follow, said Thomas J. McInerney, chief executive of Genworth. And, for now, there is an ample supply of workers to serve as at-home caregivers.

That may change in the longer term. As baby boomers age, demand for caregivers is likely to increase, since most people want to remain at home as long as possible, said Mr. McInerney. It’s also possible the cost of hiring a caregiver may be affected by new rules, which kick in next January, extending federal minimum-wage and overtime protection to many home care workers.

Extended care at home generally isn’t covered by Medicare, the federal health plan for those 65 and older. So families using such services generally pay for it out of pocket, unless they have long-term care insurance or qualify for Medicaid. Medicaid eligibility varies by state and is based on your income; you generally must have very little in the way of financial resources to qualify.

Here are some questions about hiring a home caregiver:

■ How do I know what kind of caregiver my family member needs?

You can assess needs, like his or her ability to handle activities of daily living such as dressing, eating and bathing, using a checklist, like one provided by the National Caregivers Library.

Or, you can have a professional conduct the evaluation, which is advisable, said Amy Goyer, a specialist in home and aging with AARP. To find someone qualified to do the assessment, you can contact your local office of the National Association of Area Agencies on Aging for a referral. You can find the one nearest you on the federal government’s Eldercare Locator site.

■ How do I go about finding a home caregiver?

One option is to use a home care agency, which will screen and train caregivers to make sure they can provide the level of care needed. Since the agency employs the caregiver, it also handles payroll tasks. An agency can also schedule alternative caregivers if your primary caregiver is ill or unable to work. Because the agency offers these services, its hourly rates may be higher.

■ What if I prefer to hire someone myself?

You may be able to obtain a lower rate by hiring someone directly. But if you hire a caregiver yourself, you’ll have to handle payroll and possibly taxes, said Leah Eskenazi, director of operations for the Family Caregiver Alliance, a nonprofit that helps people caring for relatives.

Ms. Eskenazi advises that word of mouth is often a good way to start your search; friends or family members who can vouch for a caregiver’s skill and reliability can be good first references. The AARP website offers a tool to search for an agency by ZIP code.

Sites like Care.com also help find independent candidates in a given geographic area. You post a job at no initial charge, and interested applicants respond with their credentials and experience; if any of their profiles look promising, you may register to obtain contact information and purchase background checks. You will have to pay a monthly, quarterly or annual fee to subscribe to the service ($35, $70 and $140). The site also offers payroll and tax services, for an additional fee.

■ Where can I find more information about home caregiving?

In addition to your local Area Agency on Aging, the Family Caregiver Alliance offers an online tool that provides links to resources in your state.

REFERENCE:

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The percentage of Americans who say they don't have health insurance dropped to 13.4 percent in April, according to Gallup.

The number of uninsured Americans has been steadily dropping since last fall, the polling company said, when a peak 18 percent of Americans said they did not have health care coverage. 

Gallup reports that number of Americans without health insurance decreased at a faster pace as the federally mandated deadline to purchase insurance arrived.

Gallup reports that percent of Americans without health insurance dropped to 13.4 during the final month Americans could sign up for health care through the federal exchange

The number of uninsured Americans has been steadily dropping since last fall when a peak 18 percent of Americans said they did not have health care coverage

African-Americans saw the most dramatic increase in health care coverage between the close of 2013, when 20.9 percent told Gallup they did not have coverage and April. Then, only 13.8 percent of blacks polled told Gallup they did not have insurance.

Hispanics continue to say they do not have health insurance at higher rates than other demographic groups. In April, 33.2 percent told Gallup they were uninsured. 

The percent of Hispanics and Americans making less than $36,000 a year who did not have coverage dropped by 5.5 percent in April, respectively. 

Gallup's numbers are consistent with a Health and Human Services report released last Thursday that showed Hispanic enrollment below what it could be and a high rate of enrollment among blacks.

More than 8 million Americans have signed up for health care insurance through the state and federal exchanges, the report said. The Obama administration did not say how many people had signed up for health care, but the number surpasses a previous report of 8 million provided by the president two weeks earlier.

The original deadline to purchase healthcare insurance was March 31. 

The Obama administration has extended deadlines multiple times to accommodate Americans having problems with government's Obamacare sign-up site, healthcare.gov, and Americans with pre-existing conditions moving out of the government's temporary high-risk pools and into the general insurance marketplace.

Gallup took its survey of 14,700 Americans from April 1 - 30. The new deadline for average Americans who had already started the sign up process to get covered was April 15. 

Some of the people Gallup polled who did not have insurance the first or second week of April may have since finished applying for coverage, potentially bringing the percent of Americans who do not have coverage down further. 

Other Americans may be waiting to get coverage until for the provision of Obamacare that requires employers to cover full-time employees to kick in at the start of 2015.

'On the other hand, it is likely that some newly insured Americans will not pay their premiums and will rejoin the ranks of the uninsured,' Gallup notes.

White House press secretary Jay Carney told reporters last week that the White House did not have, 'hard, concrete' numbers on the number of people who had both signed up for Obamacare through the federal health exchange and made their first payment.

A report issued last week by House Republicans estimated that one-third of those enrollees have not paid their premiums. The House Energy & Commerce Subcommittee on Oversight and Investigations report is based on information provided to the committee by 'all 160 insurance providers in the federally facilitated marketplace.'

The White House disputes the Republican report has not provided evidence to the contrary.

A House Republican report claims that one-third of Americans who signed up for Obamacare through the federal health exchange have not yet made their first payment on their plans

Avinash, a businessman, knows how to deal with all kinds of clients.


Avinash, a businessman, knows how to deal with all kinds of clients. However, his inexperience in finding good health insurance policies has landed him in trouble a couple of times.

In the recent past, he hasn’t been able to keep an eye on the rising premiums of his health coverage and ended up spending much more than he should have. It is essential for you to go through the policy premium rates from time to time. Several strategies can be adopted for reducing the premium over a period of time.

Rising health insurance policy premiums could be devastating because you would end up spending a big part of your income in paying them. We buy a health insurance policy to secure our future in case of a medical emergency. Even if you can’t control expenses with respect to sickness, you can definitely control the rising health cover premiums.

Avoid a policy with claim holding

Insurance firms are known to charge a huge amount of premium to cover the client, considering it is going to cover the entire cost if the policy benefits are claimed. Sometimes, when you claim the policy benefits, your insurance provider hikes the premiums for the next year. So, it becomes imperative to go for an insurance policy that entails lower burden.

For keeping a tab on premiums, it is recommended to opt for a family floater policy. These coverage policies can be taken for all your family members. They are much cheaper as the premiums are divided and you have to pay on an individual basis.

Family floater insurance policies come with a two-year waiting period and some of the diseases/disorders that are covered during that time are all kinds of duodenal or gastric ulcers, sinuses, hemorrhoids, fibromyoma, hysterectomy, cataracts, endometriosis, hernia, etc.

Opt for a policy with high top-up/deductible

People often make the mistake of going for policies with low deductibles. Overlooking the advantages of health coverage with a fairly high deductible/top-up can prove to be expensive. Here, you just have to pay a certain amount of medical cost before your insurance provider reimburses the remaining amount on your

February 25, 2014 - The Internal Revenue Service is offering educational Health Care Tax Tips to help individuals understand how the Affordable Care Act may affect their taxes.

The IRS has designed the Health Care Tax Tips to help people understand what they need to know for the federal individual income tax returns they are filing this year, as well as for future tax returns. This includes information on the Premium Tax Credit and making health care coverage choices.

Although many of the tax provisions included in the law went into effect on Jan. 1, 2014, most do not affect the 2013 tax returns.

The Health Care Tax Tips, which are now available at IRS.gov/aca, include:

·         IRS Reminds Individuals of Health Care Choices for 2014? Find out what you need to know about how health care choices you make for 2014 may affect your taxes.

·         The Health Insurance Marketplace - Learn about Your Health Insurance Coverage Options – Find out about getting health care coverage through the Health Insurance Marketplace.

·         The Premium Tax Credit? Learn the basics of the Premium Tax Credit, including who might be eligible and how to get the credit.

·         The Individual Shared Responsibility Payment – An Overview? Provides information about types of qualifying coverage, exemptions from having coverage, and making a payment if you do not have qualifying coverage or an exemption.

·         Three Timely Tips about Taxes and the Health Care Law?  Provides tips that help with filing the 2013 tax return, including information about employment status, tax favored health plans and itemized deductions.

·         Four Tax Facts about the Health Care Law for Individuals? Offers basic tips to help people determine if the Affordable Care Act affects them and their families, and where to find more information.

·         Changes in Circumstances can Affect your Premium Tax Credit? Learn the importance of reporting any changes in circumstances that involve family size or income when advance payments of the Premium Tax Credit are involved.

In addition to Health Care Tax Tips, the IRS.gov/aca website offers informative flyers and brochures, Frequently Asked Questions and in-depth legal guidance regarding the tax provisions of the Affordable Care Act.

First things first: Obtain a copy of your plan summary from human resources or directly from your insurer. Take the time to read the policy and if you don’t understand something be sure to ask questions. 

Know your plan

Doctor’s offices are not perfect and sometimes mistakes are made on your bill. Always ask for an itemized statement and review it to make sure all of the services were provided. The following notes may help you save on your out-of-pocket costs:

If you have a hospital stay planned, ask if you can bring your own regular medications. Hospitals charge by the pill and you could easily pay double what the medications cost you at the pharmacy.

Go to an in-network provider whenever possible. The insurance companies negotiate fees with doctors and decide on a reasonable price for services rendered. When you go to an in-network doctor, she may not bill you for anything other than your deductible, copayment or coinsurance. If she bills you for a higher amount than has been agreed, she must write off that amount. The doctor is not allowed to bill you for it.

Know your keywords

Copayment is a set fee that you pay for each doctor’s visit or for each medication.

Deductible is the amount you must pay before payment coverage starts. Check your plan to see if doctor’s visits and emergency room visits are paid before the deductible is met; you still have the copayment for the visit and any coinsurance will apply.

Coinsurance is the percentage of the bill you must pay. An example: For an in-network provider, you may have to pay 10 percent of the bill and for an out-of-network provider you may have to pay 20 percent. Each insurance policy is different. Once you have met your out-of-pocket maximum, the coinsurance and deductible are waived.

Contribute to a flexible spending account for medical fees. You can contribute up to $2500. If you are married you and your spouse may each contribute $2500. Depending on your plan, you may now be forced to meet a deductible before any medical fees will be covered, even doctors visits. (Note this is not how every plan works; each one is different). I have seen posts on Facebook where premiums have gone up so there will be less to bring home in a paycheck; to make matters worse they must also meet their deductible before their costs are covered. Many people will have health insurance and not be able to afford to actually use it. A flexible spending card can help. Contribute at least your deductible to the account. You will pay a set amount each pay period towards your FSA. It comes out of your check before taxes. The entire amount that you have designated is available to you at the beginning of the year. You must continue to make the contributions for the entire year unless you change employers. In that event, if what you used exceeded what you had contributed you won’t be required to pay it back. I have a friend whose child received braces and shortly after he lost his job. The braces were covered by the FSA and he didn’t pay a dime; this was before they lowered what you may contribute to the FSA. If you have funds left at the end of the year or leave the company any leftover funds will be forfeited.

Know your network

Compare the costs of procedures at different facilities. If you are having a CT scan, MRI, myelogram, ultrasound or other tests, check to see which facilities are in-network near you. This is important for the dentist as well. Make some calls to compare the prices at different facilities for that test to find the best rate. Usually you are required to pay a percentage of the testing; the lower the fee for the test, the lower your out-of-pocket costs will be. For example: If a test is $10,000 and you have to pay 10 percent, your fee would be $1,000. If the test is $6,000 your fee will be $600 dollars. Check to see if the facility requires your payment up front or if they will allow you to make payments.

Sometimes a facility will require you to pay an estimated amount before services are rendered, and then they bill the insurance company. This can result in an overpayment by you — especially if you have already met your deductible. Always check your explanation of benefits to see what your insurance company paid and what it has determined to be your out-of-pocket costs. If you paid more than you should have, call the doctors office and ask for a refund. Don’t count on them just sending it to you; most times that won’t happen.

Don’t assume that because you went to an in-network facility for testing or a hospital stay that all of the doctors who see you will be in-network. Most of the time they are not. In this case, if you went to an in-network facility most insurance companies will treat the claim as an in network one. This results in the insurance company paying a higher percentage of the bill and reduces your costs. You still will be required to pay whatever the insurance doesn’t pay, but your cost will be lower. If you are required to pay 10 percent of a $1,000 dollar bill, your fee will be $100. If you are required to pay 20 percent because it is not in the network, you would be required to pay $200. Review the explanation of benefits and if you were billed for out-of-network services at an in-network facility, call the insurance company and request it to reprocess the claim. This has resulted in refunds for me in the past.

INDIANAPOLIS, Feb 10, 2014 (BUSINESS WIRE) -- Imagine you’ve been in the hospital. You’ve eagerly waited for the day you could go home. When that day finally arrives, you’re thrilled. It’s a safe bet the last thing you want to do is to have to return to the hospital.

Unfortunately, far too many people are returning to the hospital after receiving care there, particularly seniors. According to a study published in the New England Journal of Medicine, nearly one-fifth (19.6 percent) of traditional Medicare beneficiaries who had been discharged from a hospital were re-hospitalized within 30 days, and 34 percent were re-hospitalized within 90 days.1 The Medicare Payment Advisory Commission has estimated the cost of hospital readmissions at $15 billion.

“We know that many of these instances are unavoidable,” said Dr. Mary McCluskey, chief medical officer of WellPoint’s Government Business Division. “However, some are preventable, which is unfortunate since hospital stays can expose patients to a host of complications, including possible infections, as well as being costly, stressful and inconvenient.”

WellPoint, which serves thousands of seniors through its affiliated Medicare plans, offers the following tips for making sure a hospital stay doesn’t end up turning into a round-trip.

Understand discharge directions. The transition home really starts before the patient leaves the hospital. It is critical to understand hospital discharge directions. This isn’t as easy as it sounds since patients may be medicated, stressed, groggy or confused. For that reason, it is recommended that patients repeat instructions to their physicians to make sure they understand them. It also may help to write down the instructions or enlist a family member or caregiver to help document them. Another way for a patient to smooth the transition home is to make sure someone at the hospital contacts their primary care physician (PCP) with information about their condition and treatment. People with chronic conditions see many different doctors. It is important for those doctors to communicate with each other.

Fill prescriptions and take them as prescribed. Upon being discharged from the hospital, it is important to fill prescriptions immediately and take them as prescribed. Patients should make sure to understand the timing, dosage and frequency of each drug. Also, patients should take care to understand how existing medicines, including over-the-counter drugs, interact with new drugs. Finally, if any drugs have been stopped, it’s important to ask why. It may be helpful to get a pill organizer to keep track of medicines.

Get follow-up care. According to America’s Health Insurance Plans (AHIP), half of patients who were re-hospitalized within 30 days did not have a physician visit between the time of discharge and re-hospitalization, suggesting one of the reasons people end up back in the hospital is lack of follow-up care. That is why it’s so critical for people to transition from the hospital to their PCP. Patients should schedule follow-up appointments with their regular doctor and keep them. The PCP can coordinate care, making sure patients aren’t exposed to dangerous drug interactions or unnecessary tests. Anyone with trouble getting a timely appointment can call their insurer for help.

Eat properly. People recently discharged from the hospital need to get proper nutrition, including following any dietary restrictions. Appetite is often suppressed after an illness; however, if someone is too sick to eat due to pain, nausea, inability to swallow, etc., then they should contact their doctor.

Take advantage of programs that are there to help. People with Medicare Advantage plans may have access to resources, including case managers, to help them return safely to their homes. Case managers may be able to help a recently discharged patient find transportation to doctor appointments, address potential safety issues in the home and help them locate community programs offering everything from meal delivery to free or discounted medicines. These people are experts at understanding the system and it is their job to help.

Know when things aren’t getting better. Patients should understand which symptoms require immediate intervention and return to the hospital, if necessary. People who aren’t getting better shouldn’t wait for their next appointment.

Be an engaged consumer. Many trips to the hospital occur without warning. However, people with advance notice have resources available to help them research quality and cost. Information about readmission rates for certain hospitals, for example, is available at www.hospitalcompare.hhs.gov , where visitors can enter a procedure and a zip code, select three hospitals, and click “Outcome of Care Measures” to compare results.

“Most of us will have to go to the hospital at some point in our lives,” said McCluskey. “The key is being an engaged patient to prevent hospitalization from becoming a downward spiral, both physically and financially.”

WellPoint affiliates are PPO plans, HMO plans and PDP plans with a Medicare contract. Enrollment in WellPoint affiliated plans depends on contract renewal.

1 Jencks SF, Williams MV and Coleman EA. “Rehospitalizations among Patients in the Medicare Fee-for-Service Program.” New England Journal of Medicine, 360(14): 1418-1428, April 2, 2009.

SOURCE: WellPoint

WellPointDoug Bennett Jr., (502) 889.2103 Doug.BennettJr@wellpoint.com