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Every health plan has been doing this for years. They too have treasure troves of data... they have care coordinators, patient centered medical homes, etc. So

Every health plan has been doing this for years. They too have treasure troves of data... they have care coordinators, patient centered medical homes, etc. So, how are you actually trying to change the statistics?

Mz 10y ago
Every health plan has been doing this for years. I processed insurance claims for over five years and that was not my observation. Granted, it was one company, I processed accident claims and it was supplemental coverage. But when I was there, I was initially encouraged by the trend towards adding "wellness benefits" because I had naïve fantasies this meant they were working towards getting people healthier. Nope. It was entirely about "If we offer specific tests and call them wellness benefits, we have higher retention." That was it. There was zero interest in actually making customers healthier. And I was horrified and I am pretty cynical these days. So, I guess, I am wondering if you have supporting evidence? (Links to articles, stats, etc?)
ubernostrum 10y ago
This isn't my first insurance company. The typical experience in insurance is that those tools mostly only come out once someone already has the expensive problem, and are used to manage the cost of it after the fact, rather than prevent it from happening in the first place. Also most insurance companies aren't really set up to do preventive work to the extent we do (which involves home visits from nurses and other clinical staff, staying in touch and proactively reaching out when there seem to be problems, etc. etc.), largely because they consist of essentially competing divisions which each own a subset of the data and responsibilities and jealously guard against every other division. I worked in a company like that, once upon a time -- everyone had very clearly-defined limits to their responsibilities (well beyond what privacy rules required) and even just contacting someone in a different department to make them aware of a problem or pass along a suggestion would trigger turf-war consequences. I'm very happy to now be working with the opposite of that. Finally, it's worth noting that although there are a lot of dismissive comments about tech in this thread (and some of it I can understand -- most of what we do is internal-facing and harder to promote as a result), the perspective inside is pretty different. It's true there's not a ton we're doing that's cutting edge and "sexy" tech (though we have open-sourced some neat tools for temporalizing SQLAlchemy's ORM), but that's because health care hasn't yet caught up to just the boring everyday things we take for granted. There's an example that really drove it home for me, from about six months ago. Claims are obviously a big part of what we're about, and so we have an internal team that reviews processed claims for accuracy. They have to check against a pretty complex set of Medicare claim-processing rules, part of which involves rules about combinations of medical procedures (i.e., Procedure A might be allowed but only if alongside Procedure B, or A might only be allowed without B, or A and B might just be independent and can both appear or not appear). The canonical source for that data is... gigantic Excel spreadsheets of all the procedure codes and rules. And so the claims-review team would open up Excel, type in a code, wait five minutes while it churned to find the code, then repeat for the next code, etc. An engineer saw this and spun up a two-day project to ingest those spreadsheets (on an ongoing basis, since they change over time) into a database and wrap a search interface around them which allowed punching in all the codes and getting back a list of rules and an indicator of whether they'd been violated. To tech people that's so mundane it almost puts you to sleep, and makes you say "wait, that's it?". But to healthcare people, it was a gigantic step forward. So many people from health backgrounds came from places that never let them work side-by-side with tech staff and figure out what was possible (or where all tech was outsourced to vendors with opaque planning and feature-request processes), which is why so much of healthcare tech feels decades out of date. So just having tech and medical/insurance people in the same room, working and talking together every day, acts as a pretty impressive multiplier compared to traditional insurance companies.
- coldcode 10y ago
  Also worked at a Healthcare (claims processing) company owned by multiple giant insurance companies. I never thought of it as healthcare but just health plumbing, all we did is push HIPAA data from point A to point B. And we also had horrible turf wars and insanely stupid projects that did no one any good. What you are doing is far more interesting. It was pretty obvious that there is a lot one can do with data, assuming you can deal with the HIPAA limitations. One ill person is hard to get much from, but 10000 is different story.
- roymurdock 10y ago
  Thanks for taking the time to write up your experiences here. Much more informative than the Bloomberg article. I agree that culture/what management knows and focuses on can make a huge difference, especially in a field like medicine where there are so many rules and regulations around data and expensive industrial equipment that the market can take a while to catch up to consumer/enterprise tech. I wouldn't be surprised to see you guys getting acquired by a Bigco insurance. I'm guessing that's an exit your investors are hoping for and part of a reason for the Bloomberg article, to start getting the company on the biz radar.
exelius 10y ago
Ehhh... not so much. Some of the mid-size companies are okay at this; but the low-end guys are very, very unsophisticated (there are a lot of local / state plans as mandated by various state laws) and the super-big guys just have so much stuff they have no idea how to integrate it all. Think 15-20 different, incompatible claims systems with overlapping numbering schemes, different versions of schema, different versions of underlying DB required, etc. Then do the same with provider management systems, contracting systems, etc. You get the point. By the time you get halfway through scoping out a project, the architecture will be obsolete. Oh and also the federal government keeps changing the rules about ICD-10, ACA, Medicare reimbursement, and a whole bunch of other stuff, so make sure you add in that capability to all existing systems and don't get sanctioned. A lot of companies are having a hard time keeping their heads above water. The big guys are going to eat the data-hungry guys. Or rather, the big guys will buy the best of the new data-first health plans (Clover, Oscar, etc.) for their platforms and migrate everything onto them.

Mz 10y ago

Every health plan has been doing this for years. I processed insurance claims for over five years and that was not my observation. Granted, it was one company, I processed accident claims and it was supplemental coverage. But when I was there, I was initially encouraged by the trend towards adding "wellness benefits" because I had naïve fantasies this meant they were working towards getting people healthier. Nope. It was entirely about "If we offer specific tests and call them wellness benefits, we have higher retention." That was it. There was zero interest in actually making customers healthier. And I was horrified and I am pretty cynical these days. So, I guess, I am wondering if you have supporting evidence? (Links to articles, stats, etc?)

ubernostrum 10y ago

This isn't my first insurance company. The typical experience in insurance is that those tools mostly only come out once someone already has the expensive problem, and are used to manage the cost of it after the fact, rather than prevent it from happening in the first place. Also most insurance companies aren't really set up to do preventive work to the extent we do (which involves home visits from nurses and other clinical staff, staying in touch and proactively reaching out when there seem to be problems, etc. etc.), largely because they consist of essentially competing divisions which each own a subset of the data and responsibilities and jealously guard against every other division. I worked in a company like that, once upon a time -- everyone had very clearly-defined limits to their responsibilities (well beyond what privacy rules required) and even just contacting someone in a different department to make them aware of a problem or pass along a suggestion would trigger turf-war consequences. I'm very happy to now be working with the opposite of that. Finally, it's worth noting that although there are a lot of dismissive comments about tech in this thread (and some of it I can understand -- most of what we do is internal-facing and harder to promote as a result), the perspective inside is pretty different. It's true there's not a ton we're doing that's cutting edge and "sexy" tech (though we have open-sourced some neat tools for temporalizing SQLAlchemy's ORM), but that's because health care hasn't yet caught up to just the boring everyday things we take for granted. There's an example that really drove it home for me, from about six months ago. Claims are obviously a big part of what we're about, and so we have an internal team that reviews processed claims for accuracy. They have to check against a pretty complex set of Medicare claim-processing rules, part of which involves rules about combinations of medical procedures (i.e., Procedure A might be allowed but only if alongside Procedure B, or A might only be allowed without B, or A and B might just be independent and can both appear or not appear). The canonical source for that data is... gigantic Excel spreadsheets of all the procedure codes and rules. And so the claims-review team would open up Excel, type in a code, wait five minutes while it churned to find the code, then repeat for the next code, etc. An engineer saw this and spun up a two-day project to ingest those spreadsheets (on an ongoing basis, since they change over time) into a database and wrap a search interface around them which allowed punching in all the codes and getting back a list of rules and an indicator of whether they'd been violated. To tech people that's so mundane it almost puts you to sleep, and makes you say "wait, that's it?". But to healthcare people, it was a gigantic step forward. So many people from health backgrounds came from places that never let them work side-by-side with tech staff and figure out what was possible (or where all tech was outsourced to vendors with opaque planning and feature-request processes), which is why so much of healthcare tech feels decades out of date. So just having tech and medical/insurance people in the same room, working and talking together every day, acts as a pretty impressive multiplier compared to traditional insurance companies.

coldcode 10y ago
Also worked at a Healthcare (claims processing) company owned by multiple giant insurance companies. I never thought of it as healthcare but just health plumbing, all we did is push HIPAA data from point A to point B. And we also had horrible turf wars and insanely stupid projects that did no one any good. What you are doing is far more interesting. It was pretty obvious that there is a lot one can do with data, assuming you can deal with the HIPAA limitations. One ill person is hard to get much from, but 10000 is different story.
roymurdock 10y ago
Thanks for taking the time to write up your experiences here. Much more informative than the Bloomberg article. I agree that culture/what management knows and focuses on can make a huge difference, especially in a field like medicine where there are so many rules and regulations around data and expensive industrial equipment that the market can take a while to catch up to consumer/enterprise tech. I wouldn't be surprised to see you guys getting acquired by a Bigco insurance. I'm guessing that's an exit your investors are hoping for and part of a reason for the Bloomberg article, to start getting the company on the biz radar.

exelius 10y ago

Ehhh... not so much. Some of the mid-size companies are okay at this; but the low-end guys are very, very unsophisticated (there are a lot of local / state plans as mandated by various state laws) and the super-big guys just have so much stuff they have no idea how to integrate it all. Think 15-20 different, incompatible claims systems with overlapping numbering schemes, different versions of schema, different versions of underlying DB required, etc. Then do the same with provider management systems, contracting systems, etc. You get the point. By the time you get halfway through scoping out a project, the architecture will be obsolete. Oh and also the federal government keeps changing the rules about ICD-10, ACA, Medicare reimbursement, and a whole bunch of other stuff, so make sure you add in that capability to all existing systems and don't get sanctioned. A lot of companies are having a hard time keeping their heads above water. The big guys are going to eat the data-hungry guys. Or rather, the big guys will buy the best of the new data-first health plans (Clover, Oscar, etc.) for their platforms and migrate everything onto them.