Changing Healthcare, a 15 Minute Explainer

The how, what and why of revolutionizing the healthcare system

Introduction

We are going to demonstrate a completely new way to think about healthcare finance.  We are going to present a completely new way to think about medical records.  We are going to detail a plan to put these two things together, save millions of lives and trillions of dollars.

The Problem

Healthcare in the US is fine; the best even.  The problem is health insurance.  You have a bunch of bankers running companies with tens of thousands of employees who contribute nothing to the process and are housed in hundreds of huge buildings in every major city in the country while consuming valuable resources. The Commonwealth Fund published a paper about this detailing exactly how big insurance is killing people.  Our summary of their conclusions:

• Health insurance is too expensive

• Patient education is ignored.

The Solution

If we can address the two problems above, we can fix healthcare in the US.

The Concept

Health insurance companies have two inputs: a patient and a procedure.  Health insurance companies have one output: a check to the practice for the procedure performed.  That is it.  If we automate the process between the input and the output, then we have eliminated everything the insurance company does, except for transferring the money.  The only other thing we need to add would be some way to educate the patient on how to live a healthy lifestyle.  That would result in fewer claims, causing reduced rates for everyone.

The Execution

This is a high-level overview but is still going to be a bit technical.  Bear with me, the concept is pretty simple.  Most importantly, your health insurance company only returns 53% of your premiums as benefits.  We can return the 47% they waste, on average to the patient. There are other efficiencies we will explain, and a way to manage chronic, behavior-based disease.

Universal EMR

What we need to automate the insurance process is to capture the procedures performed in real time.  If this new insurance company provides the Electronic Medical Record (EMR) to the practice, we can do exactly that.  Epic, Cerner, Athena and hundreds of other vendors produce EMR systems. They are doing it wrong.  What we need is a simple, elegant program that captures everything the physician does with a universal ‘code’ set.  That way we can document the entire patient encounter without using an archaic method that only details diagnoses and procedures and ignores everything else, like ICD and CPT.  Sure, some practices or specialties do specific things that only they need.  To mitigate that we have a tool that allows us to configure a checklist or request for information from the clinician. The practitioner types in a question once and that question then appears in the medical record forever more, along with the appropriate answers.   This is fully customizable and can capture any data for recall later.  The combination of this universal code set and the configurable questionnaires comprise the entirety of the EMR, making it lightweight, configurable and easy to use.

UMLS

What we need for this EMR is a universal code set.  The smart people at the National Institutes of Health have codified dozens of disparate data sources, like SNOMED_CT, ICD9/10, CPT, plus many of the legacy EMR systems code sets into one database called the Universal Medical Language System (UMLS).  There are over 14 million concepts plus VSAC and RxNorm.  This is truly a one stop shop, and it gets even better: once you understand how this database is put together, you can look for anything using the exact same code and procedures, whether it is Epic codes or drugs or SNOMED.  Even better, there are built in programmatic crosswalks that will automatically find related concepts in another nomenclature, giving us the ability to translate back and forth almost automatically.

Patient Education

The only other thing the Commonwealth Fund paper pointed out was patient education.  If we can get Americans to move around a little and not engage in risky behaviors, they will live longer and consume fewer medical resources.   Commonwealth Fund pointed out that if you tell an American to get an Xray, MRI or some other test, they will just go get it. That points to the fact that if you make it easy for the patient to comply, they will. 

Of course, it is far easier to sit on the sofa and flip channels than get in the gym.  Since we have control of the system, through the EMR, we know when the patient reads his or her education and how long it took.  If they change their risky behavior, we can measure that with clinical data.  The patient will lose weight. The patient’s HDL will go up and the LDL will go down.  Measurable changes will happen.  When they do, we can offer discounts for good behavior.  If you don’t follow the education, your rates will increase.  This puts the teeth in the patient education that the Commonwealth Fund is calling for to save American lives and drive down the cost of healthcare. 

Other Modules

To really spur adoption, Sentia needs to provide everything the hospital or practitioner needs to get the job done.

• Integrated health and wellness
  As described above, demo on request.

• Integrated Email
  You can’t send medical information over email, it isn’t secure.  We provide an email-like interface that IS secure

• Self-scheduling
  Patients will be able to schedule a 15-30 minute appointment with a chief complaint, reducing staff.

• Questionnaires
  This eliminates the reams of paper in the waiting room, can be completed from home, or anywhere, and having to type the answers into the system.  This is also the same functionality that makes the EMR universal, eliminating the need to design and build 135 different specialties.

• Reporting
  Once this system is up and running, we can write reports to cover everything.  Profit and loss, inventory, room utilization, the answers to individual questionnaires, or the aggregate of all questionnaires.  Even a tax return is nothing more than a report that should be a one click process, when all the information is available.

• Telemedicine
  Let’s get rid of the brick and mortar completely.  Much of what happens in medicine doesn’t require a change of venue, or even a venue at all.

• DICOM/Image viewer
  The ability to share and image across the internet isn’t new, but seeing the face of your practitioner and sharing an Xray or an MRI and being able to draw on it or show a reticle to highlight structures is.

• Practice Management
  With all the modules above we have all the information we need to fully manage the practice or hospital.  Inventory, personnel, utilization, scheduling the whole ball of wax becomes a few clicks.   This is actually a fully-fledged Enterprise Resource Management system (ERP) that will allow the practice to design and maintain their own configurable processes.

How do we get there (What makes us different)?

Yes, Epic, Cerner and others are decades old and have been continually writing code and ‘improving’ their products.  Sentia has a few things they don’t. 

Architecture

Databases and applications

We have a well thought out and executed architecture that groups functionality.  We have a Single Sign On (SSO) system that is the repository of all things security (authentication and authorization) that all our modules use.  Second, we have a Master Data Management (MDM) database that holds all shared information.  Only the data for the application is stored in the application, everything that could be shared between applications is stored in the MDM. 

Back End for Front End (BFF)

Each User Interface has its own back end for front end layer that aggregates all the various database calls into one place.  Insure is our product that shows us what a patient’s insurance deductibles, co-pays and co-insurance are.  Insure also allows us to produce an accurate estimate of the cost for any procedure based on his or her current, legacy insurance and the practice’s negotiated rates.  The Insure BFF combines the Single Sign On, Master Data Management, Eligibility, Integration and of course the Insure APIs.  This gives us a single point to program against and makes code reuse as easy as possible.

Automation

We wrote a program that generates the architecture described previously.  The application API and its BFF are generated automatically.  The developer can then paste the SSO and MDM models (that were generated previously) into it from source control to have about 60-70% of the coding done on the first day of development, based on the database design.  This is how we replicate the work of literally thousands of people, like legacy insurance, with fewer than ten in the same amount of time.

Benefits of this Process

First and foremost, this is a comprehensive rethinking of healthcare finance.  Second, with the additional modules we can solve the problems identified in the Commonwealth Fund’s paper.  There are four financial benefits to this process:

1. Your old, legacy insurance company only returns 53% of your premium as benefits.  With Sentia’s new system that uses its own EMR to detect and pay for procedures we can give the patient back that 47% in lieu of a $10 per month health insurance subscription on our platform.

2. With this EMR comes the elimination of medical coding, compliance reporting through automation and insurance adjudication, cutting the financial burden on the practitioner by over $70,000 per year per practitioner.

3. Decreasing costs by providing built in, science based patient education with incentives to live a healthier lifestyle in the form of discounts for demonstrated healthy behavior through clinical data, we further reduced the cost of health insurance through increased population health and reduced payments for chronic disease.

4. By mitigating the risk of extremely high-cost care individuals through reinsurance we have further reduced costs by an average of 12.5%

There are four benefits to patients and practitioners.

1.       Reduced costs for all

2.       Increased wellness due to reduced cost and patient education

3.       Increased profits for all practitioners on the system

4.       Reduced complexity for each practice on the system, further reducing costs.

The Financials

The average monthly premium for health insurance in the US is $477 per month for a 40-year-old individual.  If we could cut this by half, and we can, that monthly premium would turn into $239.  The drop in price does not include the $70,000 each practitioner spends on EMR, compliance and efficacy reporting and billing, coding and collections.  Much of this savings would be passed on to the consumer in the form of decreased costs.  This also does not include the education windfall.  As Americans are fully informed of the consequences of their health behaviors, we have shown that they will change these behaviors, resulting in decreased risk and therefore decreased costs.  We already know that we have the best healthcare on the planet and cutting the costs down to this $239 would make it among the most affordable.  As the population gets healthier, and Sentia takes over some of the more wasteful practices, we could see this dramatically drop to the most affordable while maintaining the best quality of care.  Eventually, we will move to a pay-for-health or value-based care instead of a pay-for-procedure model.  This would give the practitioner incentive to keep his or her patients healthy instead of rewarding performance of procedures.

Conclusion

We have demonstrated a way to both reduce costs by more than half and increase the health of the affected population.  We here in the U. S. already have the best healthcare in the world, and we have shown a way to also have the least expensive.  I recommend taking a look at the Commonwealth Fund’s paper.  We have a rebuttal for each of their arguments and a concrete, well thought out, solution to solve each of the problems they identify.