Tuesday, February 12, 2008

Shaking Things Up

If you want to mess with the healthcare system of today - play with cost transparency. Carol.com does just that:
(CNN) A new Twin Cities company called Carol is trying to change that with a Web site that gives consumers a "care marketplace" to search for medical services, compare quality and price and make appointments.

Carol joins an effort to transform the U.S. health care system by putting consumers in charge and letting the market do its work.

"We want to let consumers define value," said Tony Miller, Carol's founder and chief executive officer. "We don't have care competition in the marketplace today."

The free site, which went live in January, generates revenue from health care providers who become "tenants" on the site. When a consumer sets up an appointment with a clinic or doctor on Carol.com, the provider pays the site a fee.
It is interesting to look at the responses of the nay-sayers:
But Dr. Sidney Wolfe, director of Public Citizen's Health Research Group, said the site is nothing more than advertising, and he hoped it wouldn't catch on.

"Among physicians, there's a belief that health care is too critical ... to be left to the usual marketplace," he said.

. . .

If the site becomes more comprehensive, Carol.com would be most useful to people with high-deductible plans, health savings accounts or those without health insurance, said Elizabeth Boehm, an analyst with Forrester Research who studies the health care customer's experience.

She was skeptical of the site's prospects because many people's choices are limited by their HMO.

"(Price is) just not what drives people to make their health care choices," Boehm said. "The challenge for a site like this is that while conceptually it's good ... the reality is there are only a small group of customers looking for that."
Baloney. With patients being responsible for more and more of their out-of-pocket healthcare costs, I believe this idea will catch on like wildfire.

It is interesting that the Park-Nicollet Clinic in St. Paul joined forces with the website developer. It is no secret that this healthcare system has struggled in the past to compete the competetive Twin Cities healthcare marketplace. By competing head-to-head on price, they may have found a new way to attract more patients in to their system. This in turn, may force others to follow suit or to undercut their prices (which would be good for consumers). As the company's founder and CEO, Tony Miller states:
But Miller said consumers are starting to realize that choosing cheap health care might come back to haunt them in the form of higher premiums or other increased costs. And he thinks there are plenty of people like him who might want different options for care and are willing to pay more out-of-pocket to get what they want.

He said his idea for Carol came in part from his own experience with a heart condition for which he was told he needed surgery. A second professional recommended medication, which Miller, 41, said worked.

"I had the wherewithal and some of the contacts to help me navigate and find answers in the health care system. Most consumers don't have that," said Miller, a partner in the venture capital firm Lemhi Ventures, which has invested $25 million in Carol.
Although the number of ailments are almost overwhelming to review, I found it interesting to shop by price alone for things like a root canal, asthma treatments, or what one place is charging for a cardiac CT to obtain a calcium score that throws in "free parking close to the door!"

While the number of "tenants" on the website are small now, look for this idea to grow as smaller, less known healthcare services compete head-to-head with the Big Boys of healthcare.



Jay said...


Jay Schloss here. Flashback from your days in Cincinnati.

I've enjoyed lurking on your blog for the last couple of months. I find all of your posts interesting (and some I actually agree with !!)

Your last two posts brings to mind an idea I had a year or so ago.

I too agree that increased consumer involvement in health care will be essential to bring down costs and improve quality. Clearly, if we can make this market more "capitalist" good things should happen.

What is also clear, however, is that patients have no way to objectively evaluate the quality of their care. Pricing information, such as given by Carol.com is useless unless you know that the test was indicated and of sufficient quality. We also have to know that the proper actions are taken when a study is interpreted.

Shopping for health care can never be like comparison shopping for gadgets unless we have a broader understanding of the complexity involved.

My idea grew out of the notion that health care professionals such as you and I have the ability to seek casual second opinions about health care for themselves or their family. If a family member of mine became ill, I could (and have) called up an expert in the field uninvolved in the case and gotten an opinion to confirm the managing physician is on the right track. Unfortunately, most individuals do not have that option.

If there was an available option for a casual (but expert and well informed) second opinion, I think patients would benefit and could keep their doctors "honest." Currently available health care information sites such as WebMD and volutary RN/MD question and answer sites (such as Cleveland Clinic) are really not equipped to handle the depth,complexity and privacy needed for a valuable remote consultation.

What I have envisioned is a true second opinion service financed by patients alone (or perhaps with the help of third party payors). Patients would solicit questions through an online service that has relationships with MD experts in multiple fields. With the consent of the patient, an offline confidential, well-informed
"curbside" consultation would then be carried out primarily through chart and test review (made available by the patient to the service).

I could envision myself, as a practicing electrophysiologist, having a relationship with such an online second opinion service. A patient with questions would approach this service and be referred to me as I have identified expertise in that area. The patient and service then arrange to have records sent to me. I review these and then have a limited phone consultation with the individual. At that point I should be able to answer questions as to the appropriateness of the direction of the care offered by the managing physician. I could point out some questions to ask. I could even suggest that the patient seek a local second opinion because the original MD isn't on the right track in my opinion.

How much would you pay for such a service? Considering typical MD consultative fees, I think this could be manageable given low overhead and a patient population with some financial means.

I find this idea attractive mainly to allow some degree of policing of health care, rather than as an opportunity for MDs to make more money. How many times have you witnessed shoddy health care being delivered by another MD and wished you had some way to get the patient the help he needs without violating his privacy,making a politically unsavvy move, or getting somebody sued.

I was so driven by this idea, that I began researching domain names and discussing it with an MBA I know. Ultimately I concluded that I did not have the wherewithal to make it happen. I'm not sure how financially viable it is, but I do still think it is a good idea.

Let me know what you think.

Love the blog,


DrWes said...

Jay -
Great to hear from you! Your idea has great merit, but the challenge would be the need to constantly be recruiting doctors in enough geographic locales to make this work effectively. Perhaps this idea could be paired w/a site like Carol.com - I mean they're going to have to establish multiple geographic relationships w/health services. Then again, a Wikipedia-type service that involves respected refers might also be a means to establish such a referral service, but verifying the referrers could become a nightmare.

Anyhooo, I'd have to think a bit more on this, but it's cool to share ideas....

All the best to you-


Jay said...

Thanks for your comments, Wes.

A few points require clarification.

The system would be entirely remote (web, delivered records, and phone). There would be no need for geographic referrals on this basis. Not being geographic has the obvious economies of scale and would also cut back on the local political fallout.

The reviewing physician would not enter into a true doctor/patient relationship as he or she would not actually be delivering care. My hope is that this would solve some of the liability concerns. On the other hand, there would be no way to bill for the service in the traditional way. The service would likely have to be paid for by the individual (unless insurance companies or businesses could be convinced of the service's value).

Verification of the quality of the reviewer could be accomplished most easily by "branding" the service with a trusted name in health care. An entity like Cleveland Clinic could oversee the service and be involved in the MD recruiting and reputation/quality verification. Not all MDs would necessarily have to be CCF faculty, but that would be an obvious place to start. Coupling to a tertiary care site would also have the potential to create downstream revenue through traditional on site second opinions (that of course brings a lot of lucrative testing to the institution). Alternatively, the reviewers could post a sort of online CV and it would be the job of the service to ensure the quality of the MDs.

I'm way too busy (and nowhere near the entrepreneur) to run with this idea, but it's nice to get it out for comment.


#1 Dinosaur said...

I started to comment and it morphed into a post.

Needless to say, this won't work.

Doctor David said...

I'm a little concerned about these ideas, too. The fault with the carol.com approach is exactly what Jay originally brought up... there is no objective way for a patient to evaluate the quality of their medical care, especially when it's advertised on a website. Cost is the least important factor here. Appropriateness of evaluation, thoroughness, the correct interpretation of tests, an appropriate treatment plan, and adequate follow-up are what matter. After all, you're not buying an iPod.

The online second opinion idea is similarly flawed. Without access to the complete medical picture, including examining the patient, getting a full history, and seeing test results, the second opinion will be limited and possibly give inaccurate information. If the patient needs to be examined, give a full history, and have his/her lab results interpreted... that's a second opinion, and there is already a mechanism in place for that to happen.

Jay said...

For Dr. David,

I actually agree essentially with all written above. Recognize, however, that a true face to face second opinion is likely to be far more time consuming to the patient and very politically charged. I'm sure you'll agree (assuming you are a practicing clinician) that a patient that seeks a second opinion is treated differently than others. In addition, a patient who seeks a local second opinion may find it difficult to go back to his original MD out of embarrassment or fear (even if he liked the first doctor).

My idea is more for someone who just needs some degree of reassurance that he is on the right track. This patient could also then be armed with the information needed to ask intelligent questions. The analogy again, is that of a "curbside" unofficial opinion that doctors seek on a regular basis.

I would recognize that this form of online consultation could never serve as a substitute for a true MD face to face visit.


Doctor David said...

I don't actually agree that patients who seek second opinions are treated differently. I actively encourage my patients to seek second opinions frequently. That may be a byproduct of the type of medicine I practice (pediatric oncology), though, I'll concede that. We're a small community, so I almost always know who the second opinion is coming from, and I often point the patients toward a particular expert so that the opinion they get has some value. I guess that also biases my opinion about an online "curbside", because my patients are complex enough that a curbside opinion usually does more harm than good. I guess for a more focused question, there may be some value, but only if the question is focused and the answer vague.