HealthPlanMine: Scoring the Future

31 Oct HealthPlanMine: Scoring the Future

Score (skōr) n.

1. To evaluate and assign a grade to.
2. To gain advantage in a game or contest
3. To succeed in acquiring, often by illicit means or by conquest

At the recent Health 2.0 Conference, I was able to meet some really great innovators in the Health 2.0 space. As part of the meeting, I was able to spend some time with Amy Tenderich of Diabetes Mine. This is one of the largest social networking sites for diabetes and a great example of the energy and momentum behind the patient social networking industry. Amy is a sarcastic but spot on diabetes realist, and her voice rings true to thousands of members, hundreds of partner organizations, and dozens of sponsors.

Amy recently highlighted the announcement by Wellpoint that they are planning on using Zagat to score physicians. More interesting to her, however, was the concept of patients being “scored” based on their own personal Health Care FICO score. I wrote about this the first day of the conference, and have thought significantly on how this could be implemented and used effectively within the new Health 2.0 paradigm. Amy’s voracious readers have chimed in as well. One read, Jana, posted a comment that gave me pause and an opportunity to introduce some concepts that I have been working on:

Posted by: RichW | October 30, 2007 at 06:11 PM

FICO scores for the state of our health…no way. Ours would be in the cellar. Mine would be down a mine shaft. I’m a Type 1 with heart disease and I had polio as a child. Polio is a problem because many who had it as a child become as disabled as they were before therapy when they get older. I’m in great shape – at least I think I am – but my FICO score would be terrible. When it comes to insurance companies I believe we should all just be a name and address to them. They need to know nothing more about me. Rating insurance companies and health care providers…great idea.

My response to her as posted on the website:

Jana,

I understand your concern regarding the Healthcare FICO score being used negatively “against” you by a health plan. In fact, under the current arrangement they would absolute use this type of scoring system to kick their claim denial machines into high gear.

But I can tell by your comments that you might be unaware of how insurers and the insurance industry actually works. Insurance companies are in the business of risk – they accept your premium dollars which they are anticipating will cover any “losses” they suffer due to your medical claims. As a diabetic with multiple serious medical problems you are a terrible “risk” to them because they KNOW you are going to cost them money (perhaps $40-50,000/year). Therefore, from the insurers perspective, how on earth can they “afford” to have you give them $10,000 worth of premium when they know you are going to “cost” them $50,000 in claims? What is the business model or how is that sustainable or why do you think that is cool to get $50,000 worth of value for only $10,000 dollars? What other industry would allow you to do that (er, the mortgage industry just had a little problem with doing this recently)?

So the question is, what is the business model that allows me to provide $50,000 worth of care for $10,000 each year? In the past, it has been to spread the risk of excessive claims for one individual with the minimal claims of large populations of healthy individuals. When you aggregate populations, you are able to spread risk across many people and can do quite well financially (as demonstrated).

However, I would suggest there are other ways to spread risk that might allow a viable business model to be created. What if instead of spreading risk across POPULATIONS, I chose to spread risk across TIME as well? What if instead of an all comers aggregation mechanism, I pooled my sickest patients together to create communities who help each other follow health best practices, get recommended treatments, and support each other. What if I financially rewarded this sick risk pool, not by comparing them to healthies, but by taking their aggregated FICO score and attempting to raise from whatever baseline I started? What if, as a health plan, I was rewarded year to year by the annual increase in aggregated FICO scores? What if I could use information technology, predictive modeling, evidence based medicine, concierge style medicine, and all the great tools in place to engage my patients and activate them as informed consumers?

Your very participation in this forum leads me to believe it is possible, neigh, inevitable that this is going to happen. In fact, DiabetesMine serves as an impressive aggregation mechanism and an early model of exactly what I am talking about. What if you got your insurance through DiabetesMine, had this incredible built in knowledge, support, and information resource as part of your overall care plan?

You are beginning to see what I see, that in the new Health 2.0 paradigm, your Health Plan will be your advocate and will be rewarded financially for managing your “health”care (as opposed to “disease”care). They will be incented to ensure you are getting the best treatments, quick followup, and most effective counseling to help you manage your condition.

There is a fundamental shift going on within healthcare because the system is headed for meltdown. I believe a convergence of reform initiatives, political climate, technology advances, product innovation, consumer advocacy, and absolute crisis will yield new models that enable us to “cross over” into new territory.

Tomorrow marks a new day for the health care industry. Let it begin . . . again.