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I didn't assume zero credentialed medical professionals are involved in the company. The article clearly states you have 12 nurse practitioners serving your 19,

by qwrusz 10y ago

I didn't assume zero credentialed medical professionals are involved in the company. The article clearly states you have 12 nurse practitioners serving your 19,000 members. I looked at your website too and saw some of the other clinical operations roles. I also didn't assume random engineers are making care decisions. I said this is ambiguous and I asked a question: What is that suggesting process and who is involved? The article says you are "developing software to organize the trove of data coming from workers on the ground in New Jersey, mine it for likely health problems and suggest ways to prevent them before they happen." Your website says "we’re also partners in care, using patient-centered analytics and a dedicated care management team to identify potential risks and directly provide preventive care." Well nurses generally don't know much about data science software and data scientists generally don't know much about practicing medicine or preventive care. And of course you are not a tech-led company. You are a marketing company and government contracted middle man connecting health care services to patients and handling some of their paperwork and payments. Still this is an industry entirely living off regulatory capture. I'm not accusing you of denying someone's valid insurance claims because they didn't take your eat brown rice suggestion. But you yourself claim to be an insurer "trying to change the statistics". I get the preventive care and data science shtick looks good when marketing to potential members and to potential investors. But it's not clear how you are taking on the "change the statistics" part you claim to be, which is the most interesting and important part of all this to the extent it is real as improving peoples' health and wellness, and preventing serious health problems would be amazing! So I asked a question about how the process works and who is involved as getting data and actionable data analyses to and from health care professionals in the field is not straightforward, nor is it trivial, nor is it explained anywhere.

ubernostrum 10y ago
I've left some longer comments elsewhere in this thread about the problems with typical insurers. There's a lot of low-hanging fruit out there, which many of them aren't equipped to take advantage of because of how they're structured, and don't particularly desire to take advantage of anyway. Like I said originally, a lot of insurers are content to look at the average risk, figure out a way to be profitable in spite of it, and call it a day, because the economics of Medicare Advantage have allegedly been "solved" in that sense. The way I see it, the premise of Clover is asking what would happen if you removed the corporate-organization barriers and the organizational disinclination to do much beyond just processing claims. All those easy preventive-care wins suddenly become real options, for example. And as the insurer you have all the data to identify gaps and potential problems. For example: you know someone has a prescription because you see the pharmacy claims. And you know if they stop filling it because you stop getting claims. That's a potential problem that's easy to identify, and you have the staff to get in touch and find out what happened; maybe it's as simple as finding a pharmacy that's easier for them to get to, or a service that will pick up and deliver without requiring regular trips to the pharmacy. Sometimes it's the complexity of a particular medication regime (especially since often it just comes in the form of written instructions with little context), and clinical staff or pharmacists pharmacists take a look and come up with better explanations and adherence plans. And really, just the easy obvious stuff is so copious that I suspect it's going to be years before we run out of it and have to worry about trying to come up with new ideas -- it's just that most insurers are not structured to take advantage even of stuff that's known to be helpful for people, so nobody's ever seen what happens when you try. Still this is an industry entirely living off regulatory capture. I'm not really sure what you mean by this. I'm not privy to exactly why Clover's in the Medicare space, but my inclination is that it's because Medicare provides a stable, existing and relatively well-known space to operate in, and precisely because of how it's structured and regulated it provides a few things already packaged up that you don't have to bootstrap or which aren't quite as hard to bootstrap. And although it is heavily regulated, I've seen no evidence that the regulatory structure is designed to exclude competitors or preserve existing players; for example, in January of this year, Cigna (hardly a disruptive new player) was hit with sanctions that temporarily remove their ability to enroll new members into their Medicare Advantage plans. Everything I've seen of the regulatory environment is that it's designed to ensure the safety of Medicare enrollees and to push Medicare Advantage insurers to take good care of them.

by qwrusz 10y ago

ubernostrum 10y ago

I've left some longer comments elsewhere in this thread about the problems with typical insurers. There's a lot of low-hanging fruit out there, which many of them aren't equipped to take advantage of because of how they're structured, and don't particularly desire to take advantage of anyway. Like I said originally, a lot of insurers are content to look at the average risk, figure out a way to be profitable in spite of it, and call it a day, because the economics of Medicare Advantage have allegedly been "solved" in that sense. The way I see it, the premise of Clover is asking what would happen if you removed the corporate-organization barriers and the organizational disinclination to do much beyond just processing claims. All those easy preventive-care wins suddenly become real options, for example. And as the insurer you have all the data to identify gaps and potential problems. For example: you know someone has a prescription because you see the pharmacy claims. And you know if they stop filling it because you stop getting claims. That's a potential problem that's easy to identify, and you have the staff to get in touch and find out what happened; maybe it's as simple as finding a pharmacy that's easier for them to get to, or a service that will pick up and deliver without requiring regular trips to the pharmacy. Sometimes it's the complexity of a particular medication regime (especially since often it just comes in the form of written instructions with little context), and clinical staff or pharmacists pharmacists take a look and come up with better explanations and adherence plans. And really, just the easy obvious stuff is so copious that I suspect it's going to be years before we run out of it and have to worry about trying to come up with new ideas -- it's just that most insurers are not structured to take advantage even of stuff that's known to be helpful for people, so nobody's ever seen what happens when you try. Still this is an industry entirely living off regulatory capture. I'm not really sure what you mean by this. I'm not privy to exactly why Clover's in the Medicare space, but my inclination is that it's because Medicare provides a stable, existing and relatively well-known space to operate in, and precisely because of how it's structured and regulated it provides a few things already packaged up that you don't have to bootstrap or which aren't quite as hard to bootstrap. And although it is heavily regulated, I've seen no evidence that the regulatory structure is designed to exclude competitors or preserve existing players; for example, in January of this year, Cigna (hardly a disruptive new player) was hit with sanctions that temporarily remove their ability to enroll new members into their Medicare Advantage plans. Everything I've seen of the regulatory environment is that it's designed to ensure the safety of Medicare enrollees and to push Medicare Advantage insurers to take good care of them.