Algorithms still the hottest trend in healthcare and the steering wheel that controls all. 

Here’s the press release below.  Is this too little and too late?  Risk management has been running healthcare for a very long time as the private insurers have been the up front runners with investing in technology all the way around and have some of the most sophisticated business intelligence systems in healthcare and our government is still way busy in playing catch up, so again, one more unknown coming to the plate, in what are they really offering?  Do we know?  Do they know? 

What’s the catch, protecting money is what it is all about.  Hospitals are already on the verge of going bankrupt due to low reimbursement contracts and doctors all over the country spend hours of administrative time trying to work with carriers on getting claims and referrals covered for their patients which detracts from the time spent with patients. 

One thing that is overlooked here as well is how science is evolving healthcare as well.  The cost has to be absorbed somewhere in the system and risk management and science don’t always work hand in hand, as risk management wants a return on their investments, us, and science is working to create cures and treatments, so the 2 working together just based on such different business models is not something I see as being a true reality. 

Nobody can predict with any great degree the return on science, biotech, etc, ask any Venture Capital company right now, they can tell you about risk with science, and yet too, we are still seeing many biotech companies that fail on their trials, folding up and going away, leaving all the money invested going nowhere.  Also, we have the FDA trying to restructure it’s environment and adding new technology to the entire system and playing catch up, but they are not the only government entity in the ball game, several others are doing the same. 

Insurance coverage, biotech advancements, etc. are all still a roll of the dice, and the challenge for the primary care physician to bring some of this into the current clinical world is also one big question, some don’t even want to be involved until it reaches the point to where we have FDA approved devices and drugs before they stick their neck out, and for good reason, they do have a reputation to protect and have to watch their own stands on clinical trials as nobody would want to send a patient to an area that would fail, but how do they know, well like the rest of us, they don’t. 

So in the meantime, the algorithms continue to grow and get more complicated by the day, making the goals of providing good healthcare for all just a little bit more out of reach, as you don’t see insurers investing in R and D for development of new drugs by any means, but they do invest in software to get more business intelligence reporting to further evaluate their focus of risk management.  Blue Cross even created their own venture capital group from the profits and the first announced investment they mad was in the area of business intelligence software, so that is probably a good indication of where their business model will continue to focus, and those of us that just want to get out  health needs taken care of within areas we can afford are just left out in the cold and rolling the dice.

The algorithms of healthcare as they continue to develop, fragmented and with the overall focus on risk management business models are not the answer to our current dilemma and as we continue to fuel the fire, as we have seen in the last few years it continues to elevate.  Perhaps if we could come together on algorithms with the same goal someday, we might just see some progress. 

Algorithms, good and bad business intelligence,  are still the hottest technology in healthcare, no matter how they are written and integrated into place –  these are the parameters where we have to either qualify or abide by that are getting more complex and complicated at time marches on and for risk management, they are there to help filter out the risk so they can fully take advantage of business intelligence to increase profits.  The rest of healthcare is still catching up with building algorithms to play ball with the best all star studded team that money can buy, the insurers.  BD 

Press release below:

Health Plans Offer Comprehensive Reform Proposal

Call for 30 percent reduction in cost growth;
Essential benefit plan available in all states

Washington, DC – Health plans today offered a comprehensive health care reform proposal to achieve universal coverage, reduce the growth of health care costs, and improve the quality of medical care.

“Today our board is making a strong statement that now is the time for health care reform,” said Karen Ignagni, President and CEO of America’s Health Insurance Plans (AHIP).  “Reducing health care costs, improving quality of care, and bringing everyone into the system must be done in tandem to maximize the opportunity for success on all fronts.”

The new proposal is the culmination of three years of policy development by AHIP’s Board of Directors to develop workable solutions to the health care challenges facing the nation.  It reflects the concerns and incorporates the ideas that were raised by the American people during a nationwide listening tour as part of AHIP’s Campaign for an American Solution.

“AHIP’s Board and membership are committed to working with policymakers and other stakeholders to ensure that all Americans have affordable, high-quality health care coverage,” said James Roosevelt, Jr., President and CEO of Tufts Health Plan and Co-Chair of AHIP's Policy Committee.

The new proposal outlines strategies to achieve four main objectives: controlling costs; helping consumers and purchasers; achieving universal coverage; and adding value.

Controlling costs: A financially sustainable and affordable health care system can only be achieved by bringing underlying medical costs under control.  If health care costs are allowed to continue rising at rates far exceeding economic growth, they will thwart all efforts to improve coverage and care.

Health plans are urging Congress to set a bold target of reducing the future growth in health care costs by 30 percent over the next five years.  Based on the current projected growth rate of 6.6 percent, this could produce a cumulative savings of more than $500 billion over five years.

To achieve these goals, health plans are proposing that a public-private advisory group be created to provide specific policy recommendations to Congress on reducing health care costs.  This new advisory group would include input from a wide variety of stakeholders to provide objective, independent recommendations.

Helping consumers and purchasers: Insurance market rules need to be reformed to help individuals and small businesses access affordable coverage while avoiding duplication of administrative and regulatory responsibilities. These reforms must be coupled with initiatives to provide one-stop access to coverage options and clear, consistent information on quality and cost of care.

Health plans propose that a new portable health plan be available to individuals and small businesses in all states.  This affordable “essential benefits plan” would provide coverage for prevention and wellness as well as acute and chronic care.  To maintain affordability, the essential benefits plan would not be subject to varying and conflicting state benefit mandates.

The essential benefit plan would also be made available to workers who are going through a job transition or are eligible for COBRA to ensure they are able to maintain health care coverage.

The proposal also calls for protecting low-income individuals and working families from medical bankruptcy by making available tax credits to those who spend a set percentage of their income on out-of-pocket health care expenses, including premiums and cost-sharing.

Achieving universal coverage: By addressing rising costs, reforming insurance market rules, and enhancing value in care delivery, the nation can provide all Americans – those with and without coverage today – affordable coverage they can keep.

Health plans propose guaranteed coverage for people with pre-existing medical conditions in conjunction with an enforceable individual coverage mandate.  To help working families afford coverage, advanceable and refundable tax credits should be available, phasing out as income approaches 400 percent of the federal poverty line.

The plan also calls for shoring up the health care safety net by making eligible for Medicaid every uninsured American living in poverty and strengthening the Children’s Health Insurance Program.

Adding value: The nation must create a 21st century system where quality and effectiveness are rewarded, administrative efficiency is achieved, and primary care and wellness are encouraged.

Health plans commit to streamlining administrative processes and propose making targeted investments in our public health infrastructure.  The plan also calls for refocusing our health care system on keeping people healthy, intervening early, and providing coordinated care for chronic conditions; adopting uniform standards for quality, reporting, and information technology; and investing more in research to better understand which treatments and therapies work best – for the nation as a whole and for specific patients.

To learn more about AHIP’s health care reform proposal, visit  

Related Reading:

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Governor blasts Blue Cross over confidentiality : California
Health Insurers Show 14 Percent Increase in Use of MIB Data

Judge Rules on Balance Billing in California – Physicians not be able to balance bill

Desperate Hospitals – Updated November 21, 2008

Blue Cross/Blue Shield of Massachusetts reports $57.6 million profit for the 3rd quarter

WellPoint to begin pilot Medical Tourism program with India


  1. Thanks u r information

  2. Great post. I particularly agree with your thoughts about how health insurance companies and health care have different interest and goals. With insurance companies, the goal is to pay out the least amount of claims possible; that is in essence the business model. Health care, on the other hand, looks to provide the best possible care.

    Personally, I think health insurance companies have too much power over the health care industry. And for true health care reform to occur, you can't have an entity with a conflict of interest deciding: 1) what is appropriate care and treatment for someone based on an insurance policy; 2) what is the appropriate reimbursement/cost to provide care.


  3. Thanks for the nice information. I am sure, I will tweet this to my twitter account. This will help a lot of users.


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