Tuesday, May 21, 2019

Scalability of Home-Based, Non-Medical Services is a Non-Trivial Challenge


Scalability of Home-Based, Non-Medical Services. SDOH: Social Determinants of Health. Medicare Advantage. Non-clinical supports and services patients members. Supplemental Benefits for the Chronically Ill (SSBCI)
Popular wisdom claims 80% of our health is impacted by social determinants that can be barriers to the care we’re provided and the outcomes associated with the care we receive. And over the last four to five years, healthcare industry players – providers, health systems, health plans, HHS/CMS, and other parties responsible for the delivery of health care - have finally woken to the importance of addressing social determinants as barriers by providing non-clinical supports and services to their patients and members.

It seems there’s not a vendor serving the healthcare market who’s not in the process of developing, positioning and promoting their product and service offerings as a means of addressing social determinants of health.

Build It and You’ll Have to Deliver It, Deploy It, and Support It


With any vendor’s offering, success depends on someone’s willingness to pay for their offering and their ability to deliver and depl
oy their specific offering to a large – and growing - user base willing to actually use their product or service. It’s not enough to prove the ‘success’ and value of a product or service via a pilot with a few dozen or even a few hundred individuals unless the outcomes and lessons learned from the pilot confirm that the offering can scale to address the needs of thousands, tens of thousands and greater sized groups.

Scalability of Home-Based, Non-Medical Services. SDOH: Social Determinants of Health. Medicare Advantage. Non-clinical supports and services patients members. Supplemental Benefits for the Chronically Ill (SSBCI)

Accordingly, it’s no surprise that “scalability” has become a hot buzzword among vendors and others touting SDOH-related offerings aimed at addressing barriers to improved health outcomes. Service-related product ideas are notoriously hard to scale.

Definition of Scalability: Scalability is the property of a system to handle a growing amount of work by adding resources to the system.

But just what does scalability mean in the context of delivering, deploying, and supporting SDOH-related services? Especially those considered non-medical in nature?


New Players Bring New Challenges to Scaling Services in the Healthcare Industry


Scaling delivery of products and services that are largely technology-based and deployed with little to no human involvement from a centralized location by a closely managed group of largely professional resources is an entirely different matter than scaling the deployment, configuration, and support of ‘non-technology products’ by non-medical providers across 1000’s of decentralized service locations.



Scalability of Home-Based, Non-Medical Services. SDOH: Social Determinants of Health. Medicare Advantage. Non-clinical supports and services patients members. Supplemental Benefits for the Chronically Ill (SSBCI)

Consider some of the new products and services that Medicare Advantage health plans are approved to provide their members under the recent Special Supplemental Benefits for the Chronically Ill (SSBCI) legislation:
  • Food and Produce
  • Transportation for Non-Medical Needs
  • Indoor Air Quality Equipment and Services
  • Assistive Devices and Home Modifications
  • Pest Control

All of the above are services are likely to be provided by non-medical providers with various levels of skill, subject to various local regulations in a beneficiary’s home. Scaling the delivery and ongoing support of these types of services and products to large groups of individuals presents new and unique considerations and challenges to healthcare industry players.


Considerations for Scaling Delivery of Non-Medical Products & Services


There are more than a few unique considerations and challenges related to scaling the delivery of non-medical products and services including:


Many SDOH-related Offerings are New Ground for Health Plans, Health Systems, & Providers


With the possible exception of non-emergency medical transportation (NEMT) and care coordination services, most of the non-medical products and services envisioned as reducing or eliminating barriers to health are unchartered territory for the health plans, health systems, and provider practices whose members and patients may enjoy their benefit.



Scalability of Home-Based, Non-Medical Services. SDOH: Social Determinants of Health. Medicare Advantage. Non-clinical supports and services patients members. Supplemental Benefits for the Chronically Ill (SSBCI)

While the general consensus is that plan members and health system patients will benefit from these services, they are largely preventive in nature and their impact on outcomes and their return on investment are not well known. Until a more developed evidence base showcasing the benefits of SDOH-initiatives is available, healthcare organizations will be hesitant to commit significant investment.

Non-Medical Providers Dominate Delivery of SDOH-related Products & Services


The traditional healthcare services model where a patient commutes to a centralized location where services are provided by one or more skilled resources is turned upside down.

For many of the services intended to break down SDOH-related barriers, the provider (medical or non-medical) travels to a patient home (decentralized location) and provides their product and/or service on the recipient’s turf and timeframe.



Scalability of Home-Based, Non-Medical Services. SDOH: Social Determinants of Health. Medicare Advantage. Non-clinical supports and services patients members. Supplemental Benefits for the Chronically Ill (SSBCI)

And issues with delays, availability of needed resources, and unforeseen issues preventing completion of the service event generally impact the service provider more than the patient – which is pretty much the opposite of the traditional healthcare services model.

Established Networks of Vetted Non-Medical Service Providers Do Not Widely Exist


Health plans simply do not currently have meaningful networks of providers to support the non-medical, SDOH-related service needs of their members and existing medical network providers.



Scalability of Home-Based, Non-Medical Services. SDOH: Social Determinants of Health. Medicare Advantage. Non-clinical supports and services patients members. Supplemental Benefits for the Chronically Ill (SSBCI)


While there are a few new startups in this space, UniteUS, Healthify, and Solera Health Network come to mind, they’re mostly unproven and they’re mostly addressing front-end (assessment & referral) and back-end (payment and reporting) functions; the part that technology and contractual relationships go a long way in scaling.

‘Pre-Delivery’ Identification and Selection Assessment Can't Always Be Automated


Given the relative infancy and lack of historical financial experience and quality measures on which to gauge the value of certain SDOH-related offerings, healthcare organizations are looking for objective criteria to help them determine which of their members and patients may benefit the most from SDOH-related products and services. 


Scalability of Home-Based, Non-Medical Services. SDOH: Social Determinants of Health. Medicare Advantage. Non-clinical supports and services patients members. Supplemental Benefits for the Chronically Ill (SSBCI)

Knowing which member or patient to invest in ’upfront’ is not only a smart business decision but in some cases like Medicare, a requirement to document how beneficiaries are selected to receive supplemental benefits.

Some Processes Just Can't be Effectively Automated


While artificial intelligence, predictive analytics, and other ‘black box’ technologies can certainly assist with scalability in this front-end function, many SDOH barriers to health must be physically assessed by a skilled resource. Traditionally, medical professionals may ‘guess’ as to which non-medical benefits their patients may benefit from in their home. In many instances, occupational therapists may need to provide this guidance via in-home visits.

Again, home-based visits to assess need will impact the ability to scale.


Different SDOH-Related Barriers Require Different, Sometimes Scarce Skill Levels


Some SDOH-related services, like non-emergency medical transportation for example, generally require only a licensed driver with auto insurance able to pass a cursory background check. Other services like addressing indoor air quality and installing safety equipment require more specialized, skilled or semi-skilled technical knowledge. On-site home assessments may demand more highly-skilled resources like an occupational therapist.

Scalability of Home-Based, Non-Medical Services. SDOH: Social Determinants of Health. Medicare Advantage. Non-clinical supports and services patients members. Supplemental Benefits for the Chronically Ill (SSBCI)

In all cases, the increasingly tight labor market and a dearth of skilled and semi-skilled labor resources will hamper scalability. Remember the definition of ‘scalability’ noted above?

Products & Services Can Be Subject to Local, County & State Licensing & Regulations


Individuals and companies wanting to provide non-medical products and services able to address barriers to health must meet various levels of licensing and regulations from local city, county, state, and even federal entities. Some of these ‘credentialing needs’ for non-medical providers include:
  • Valid driver licensing and auto insurance verification
  • Background checks of various levels
  • Compliance with local, county, state and federal licensing
  • Bonding and insurance
  • Certification in various skills, disciplines, and capabilities
  • Good standing with the registrar of contracts or local residential licensing boards


Deploying Products & Services in the Field (Home) Can Involve Significant Overhead


For services other than non-medical emergency transportation, traveling to and from a health plan member’s or health system patient’s place of residence can add significant overhead to what might otherwise be a straightforward service provision. And when any myriad of issues arises as they most certainly will, a second trip - or even third or fourth trip - to complete a specific service call can greatly impact the delivery schedule and financial viability to the non-medical provider.

Best Buy’s purchase of GreatCall was an ingenious move that not only opened up Best Buy’s retail channels to Great Calls product but also positioned Best Buy’s Geek Squad to support various levels of virtual and in-person, in-home support of Great Call’s personal emergency response systems.


Non-Medical Offerings Require ‘Post-Service Delivery’ Feedback


On the back end, it’s critical to all those involved in receiving, providing, and paying for these new non-medical services to be able to identify, capture, track and understand how they each benefit. Payers will be loath to pay for services without some understanding of the return on investment obtained.



Scalability of Home-Based, Non-Medical Services. SDOH: Social Determinants of Health. Medicare Advantage. Non-clinical supports and services patients members. Supplemental Benefits for the Chronically Ill (SSBCI)

So, while a lot of front-end beneficiary selection, service scheduling, and back-end reporting may be addressed via scalable automation, a good part of the front-end assessment and post-service referral closure reporting will likely entail a significant manual component – further impacting scalability.


Contracting and Payment for Non-Medical Products & Services


Contracting with non-medical providers and processing payments for the services and products they provide is new ground for healthcare organizations. While it’s expected that a process similar to the traditional method of claim-based billing will be used, there are a lot of moving parts in regard to payment for non-medical services.

Scalability of Home-Based, Non-Medical Services. SDOH: Social Determinants of Health. Medicare Advantage. Non-clinical supports and services patients members. Supplemental Benefits for the Chronically Ill (SSBCI)


And the new cohort of non-medical providers responsible for billing and collecting for their services will need to rapidly climb the often-convoluted healthcare billing curve.

RELATED: Who, What, & How: Understanding New SDOH Payments in Medicare Advantage 


Specific Actions, Thoughts & Ideas to Scale Delivery of Non-Medical Products & Services


In a following post, I’ll share some actions, thoughts, and ideas on how to address what I’ve presented above. In the meantime, consider following me on Twitter and reach out to me here if you’re a health plan, health system, healthcare provider - or even just an individual - with a specific question or need regarding how simple, non-medical products and services can help improve or maintain health outcomes.

Monday, May 6, 2019

Insight on Expanding ICD-10 Codes to Support Social Determinants of Health


The 16th Annual WorldHealth Care Congress (WHCC19) took place in Washington DC last week. 

What a great mix of people sharing ideas, opinions, policies, technologies, and regulations - and other thoughts on their minds - for transforming our screwed-up healthcare system in the United States! 

And I was given the opportunity to attend and participate in this gathering of healthcare leaders, champions, thought-leaders, media personalities, influencers and others attending the WHCC19 event.

Social Determinants of Health - aka. Barriers to Health

As has been the case for most healthcare-related conferences over the past few years, ‘social determinants of health’ (SDOH) were one of the hot topics – if not THE hottest topic at the event.


Small Sample of Previous Shares on SDOH

Given my personal interest in addressing social determinants of health and the barriers to care they present, I’m going to share some information about social determinants of health that I observed at the WHCC19 event. 

What was shared in sessions, what I heard in the hallways, and what journalists and others shared during and after this year’s WHCC event.

RELATED: More Social Determinants of Health





WHCC TV Shares Great Insight in Snackable Bites

My first share will be a transcript of Mabel Jong’s interview with Sheila K. Shapiro, SVP of National Strategic Partnerships - Clinical Services at United Healthcare. 

I’ll add some links and commentary to this post to hopefully add some context and value to Mabel Jong's interview.

[For other Healthcare Conference Goers like me, you’re probably aware of the trend that started about 5-6 years ago where conference organizers do live interviews during their events. While we all have our favorite interviewers, it would be hard for anyone to argue that Mabel Jong is NOT among the best true journalist interviewers: smart, engaging, and not giggling all the time.]

Need for Coding Social Determinants Explored at WHCC19


Mabel Jong:
Good morning, I'm Mabel Jong. Thanks for watching continuing coverage of the World Health Care Congress here on WHCCTV

We're going to be talking about the work with [medical] codes and we're going to do that with Sheila Shapiro who's Senior Vice President - National Strategic Partnerships - Clinical Services at United Healthcare. Sheila thank you so much for your time.

Sheila K. Shapiro:
Gosh thank you for having me.


Mabel Jong:
So, you spent a lot of your time at United Healthcare thinking about [medical] codes and working with those. Tell me where you're at with that now and why it's significant.

Sheila K. Shapiro:
Well at United Healthcare we're really looking at redefining healthcare to whole person health. And one of the things that we've been doing over the last several years is looking at how we can capture information related to social determinants of health and take action on that information.

Yes! We Need to Speak a Common Language

And one of the key things that need to be done in order to utilize information is to have a common language. And that the common language that we are promoting is the use of ICD-10 coding - those are diagnosis codes that physicians and the healthcare community use to share information with each other about an individual.

Just like when you go to the doctor and they diagnosed you with some condition - maybe diabetes.



Now everyone within the healthcare system can understand what that condition is and work to solve that problem. The same thing goes with the [diagnoses] codes that we have been asked - that we have requested from the ICD-10 committee to assist the industry in getting that common language by expanding those codes for social determinants of health.

Y'all Cool with United Health Care Setting the Agenda?


Mabel Jong:
Okay. Why is United Health Care taking the lead on this?

Sheila K. Shapiro:
Well, we believe that every individual regardless of whether they are uninsured or underinsured should have access to care. And that care includes social determinants of health. So, we believe taking that information and being able to utilize it to help our members lead healthier lives is part of our mission.

And in that regard, we have already had members tell us that they need assistance. And over 2 million of them so far have asked for that help and we've been able to make referrals for over a million people already. That equates to over a quarter of a billion dollars of social value to the people that we're trying to serve.


Who’s Involved With Defining ICD-10 Codes for SDOH?


Mabel Jong:
Is the rest of the healthcare community happy to let United [United Health Care] take the lead in establishing the codes for the social determinants of health area?

Sheila K. Shapiro:
We are partnering with many different organizations. We have a collaboration with the American Medical Association, the National Association of Quality Assurance [Sic: per transcript]- now NCQA. And many state regulators - one of them being the Medicaid agency in Arizona known as AHCCCS

[Comment from Steve: Oh Boy! Now we know we're hosed because the AMA wants to somehow start collecting royalties on SDOH coding!]

RELATED: ICD-10 Codes Covering SDOH - From AHCCS.

We have the National Association of Community Health Centers and many other organizations - including payers - are coming together to really think about how we simplify this work so it can fit into the workflow of not only health payers but providers. So, leveraging those ICD-10 codes that are used today for diagnosis actually create that common language for the industry.

Another Patented Algorithm from Large Payers & American Medical Association?


Mabel Jong:
Okay. How far into the work are you now and where do you want to end up?

Sheila K. Shapiro:
So, we know at UnitedHealthcare that this is a journey and we have just begun to think about how to incorporate social determinants of health into whole person care. 

And we believe that redefining healthcare is part of our mission. As we have done this work, we've begun to partner with various social and governmental agencies to provide those referrals. That's where that social evaluation also begins to play a critical component.

So, we have a patent-pending imputed market price social valuation model that allows us to take that information around a referral and that fulfillment of that service and understand how that affects people's overall quality. 



[Comment from Steve: Oh Shit! Another 'patented algorithm' from a corporate entity!]

And the outcomes that we're trying to achieve for the populations that we're here to serve.

[Comment from Steve: Who does UHC serve? Shareholders or executives? Members?]

Impact of ICD-10 Codes for Social Determinants of Health


Mabel Jong:

Would that replace anything that's already in place now or it would become a completely new tool?

Sheila K. Shapiro:
It's not a new tool at all and that was really what we were striving to stay away from because we know that the system is taxed and our providers are already have a significant workload - which is why we were looking at the ICD-10 codes to leverage. [i.e. Codes to track SDOH, mostly so-called 'Z-Codes.']

There are existing codes around social determinants that many doctors already bill on their claim forms. The codes that we are asking for really are an extension of that - to allow all of us within the system to help each other. 

So, when we make a referral today, we're able to share that information back with our providers through existing mechanisms - not new tools.

Social Determinants of Health at WHCC19


Mabel Jong:
Alright Sheila Shapiro. Thank you so much. May I ask how you're enjoying the conference?

Sheila K. Shapiro:
So far I love the conference. You know I think all the speakers are great. We really appreciate the World Health Care Congress allowing us to come participate. United Healthcare knows that social determinants are a critical part of people's overall health.

And we are anxious to see that whole person care become a reality.

Mabel Jong:
All right Sheila. Thank you again. And I'm Mabel John thanks for tuning in.


Sunday, December 9, 2018

Collection of Healthcare & Healthcare Technology Predictions & Trends for 2019

healthcare predictions and trends for 2019 healthtech digitalhealth
It’s prediction season and all of the experts, thought leaders, consultants and others operating in and around the edges of the healthcare industry are sharing their lists of predictions and trends expected to take place in 2019 and beyond.

For the fourth year in a row – I’m sharing a list of lists I believe are fit for sharing. That means lists that are not ALL overly broad and that are detailed enough to provide some level of value to you the reader.

Previous Lists of Healthcare Predictions Most Popular of All My Blog Posts


The following three lists of healthcare predictions and trends have been among my most popular blog posts over the last three years.





{I get that sharing others work is no special feat on my account}

More Healthcare Predictions & Trends are Coming Soon


One prediction you can be sure to come true is that more ‘Top Healthcare Predictions & Trends’ lists will be released over the next few weeks as 2018 winds down. 

As in previous posts, I’ll update this post with new information as I find them.  So bookmark this page – or better yet – subscribe to this blog and/or follow me on Twitter so you’re easily kept in the loop on what to expect in 2019 and beyond.

healthcare predictions and trends shimcode blog digitalhealth hitsm hcldr leadership social media


General Predictions & Trends on Healthcare in 2019
















Healthcare Technology-Related Predictions & Trends










Top Technology Trends You Need to Prepare for in 2019 [By Industry]

3 Insurance Technology Trends That Will Rule The Roost in 2019 - Added 12/28/18

The top digital health trends of 2019 - Added 12/28/18

Five innovation trends that will impact the healthcare industry in 2019 - Added 01/04/19

Top 5 Technology Trends to Reshape Healthcare in 2019 - Added 01/04/19

12 trends that will dominate healthcare IT in 2019 - Added 12/28/18

Predictions & Trends on Subsets of Healthcare










Share What You Find


If you have any of your own predictions or know of lists that I can add to this post, please share them in the comments or send them to me at info@shimcode.com. I'll add them and attribute them to you - if you want me to do so.