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It’s a Bird! It’s a Plane! No, Just Another Healthcare Disruptor!

As with many things in life, change is challenging, often undetected when it starts, many times mislabeled as an aberration, but always important. As John F. Kennedy once said, “Change is the law of life, and those who look only to the past and present are certain to miss the future.”

One of my favorite word pictures about a health insurance company is:

  • A health insurance company is like a car racing down a winding mountain road with no guardrails.
  • The windshield is painted black, and you can’t see out.
  • The CEO is driving the car with blinders on.
  • The Sales manager is pushing the accelerator down as far as possible.
  • The Underwriting manager is desperately pushing down on the brake.
  • While the actuary is looking out the back window telling them where they have been.

In this picture, the health insurance company is looking to the past and present with no idea about what is around the corner.

A critical change that is occurring right now in today’s healthcare system, and frankly, one that is improving it, is the introduction of new entrances to the system itself. Up until recently, one entered the system primarily from three doors: the doctor’s office, the emergency room, and in some cases an urgent care center. This is changing right in front of our eyes.

A critical change that is occurring right now in today’s health care system, and frankly, one that is improving it, is the introduction of new entrances to the system itself.

COVID-19 accelerated and validated the use of virtual visits. Technology had been available for years and CMS and carriers resisted paying for them, but the pandemic created a healthcare crisis and today we can’t live without them. Anyone with a smartphone has what it takes for a virtual visit to happen. Most carrier patient portals provide the option to request a virtual visit. Few providers resist since it improves their operational efficiency and compensation for them is reasonable.

Perhaps a more significant change, and one much less noticed today is what happens in an aid car or ambulance much of the time. Thanks to the CMS ET3 program, emergency first responders are beginning to provide meaningful care to emergent patients. In the past, a trip to the hospital was required for reimbursement. Thanks to thoughtful planners realizing what capable and appropriately trained EMS/EMT professionals can do, first responders can provide necessary and life-saving care while transporting the patient. For example, provide care for critical stroke patients, administer injectables to counteract specific issues, and many others. In addition, they now can avoid the expensive emergency room and transfer the patient to an appropriate setting (e.g., a physician’s office) and be reimbursed for the trip. The traditional triage role of an emergency room now in many cases has been moved to aid care.

So why are these changes so important? In the past care managers were trying to avoid unnecessary admits and reduce length of stay. This oftentimes resulted in a transition to lower costing care settings (e.g., step-down units, sub-acute stays, SNF stays, etc.). In many cases, care was transitioned to an outpatient setting further reducing healthcare costs and improving quality. Clinical and actuarial studies showed large amounts of potentially avoidable care in the emergency room, perhaps as much as 35% – 50% of the visits being unnecessary.

Emerging changes provide a new path to improve the system, although opening new avenues to the system that need careful management and oversight.

Inside the emergency room itself, variations in care patterns are substantial, including unnecessary admissions to the hospital from the ER, unnecessary and excessive numbers of tests with limited value, not to mention the significant number of patients that could and should be treated elsewhere or not at all. This portion of the healthcare system has played a hidden role in raising the cost of the healthcare system. The emerging changes provide a new path to improve the system, although opening new avenues to the system that need careful management and oversight.

A recent informal poll of healthcare experts showed fear of virtual visits, a lack of awareness of the ET3 program, and concern without a solution for improving the cost and efficiency of today’s healthcare system. Back to John F. Kennedy, are we just missing the future? Hopefully not. Perhaps Albert Einstein was correct when he said, “The measure of intelligence is the ability to change.” The system is changing, but let’s utilize this change to improve the entire healthcare system.

We at AHP are focusing many of our development efforts on this change. We are actively at work in multiple venues:

  • Our Axene Continuing Education, LLC subsidiary has developed a best-in-class continuing education curriculum to educate EMS first responders and help them provide the best possible care to their patients.
  • Our clinical practice has developed assessment tools and related resources to quantify the potential for hospitals and health systems to improve their emergency room operations and financially thrive under the emerging value-based reimbursement methods.
  • Our actuarial practices have utilized its extensive proprietary data sources to develop actuarial models and benchmarks to compare actual health system results to both normative national and local markets using best-in-class tools (e.g., 3M CRG and PPE groupers).
  • Our consultants are actively applying this knowledge in multiple market sectors (e.g., Private Equity Investors, Group Purchasing Organizations, etc.) and at times collaborating with other firms.
  • Our consultants have developed specialized tools to help improve both provider and payer performance in the market (i.e., PI Squared, VBR Risk Assessment, etc.).

To learn more about how AHP can help your organization, email us at hello@axenehp.com

About the Author

David AxenePartner and Consulting Actuary
David Axene, FSA, FCA, CERA, MAAA, is the President and Founding Partner of Axene Health Partners, LLC

Any views or opinions presented in this article are solely those of the author and do not necessarily represent those of the company. AHP accepts no liability for the content of this article, or for the consequences of any actions taken on the basis of the information provided unless that information is subsequently confirmed in writing.


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