The Patient Paradigm

Shifts

The Patient Paradigm

Shifts
Profiling the New Healthcare
Consumer
Judy L. Chan

The Patient Paradigm Shifts: Profiling the New Healthcare Consumer

Copyright Business Expert Press, LLC, 2016.
All rights reserved. No part of this publication may be reproduced,
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First published in 2016 by
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ISBN-13: 978-1-63157-409-2 (paperback)
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To the loves of my life, my husband Ken and daughter Caitlin,

forbeing you.

To my mother who loves and always cares about others.

To the two men who influenced me the most and left the world a
better place
My father who instilled in me that I can do anything
Iwant in life and live it to the fullest.
My piano teacher for 31 years, Thomas LaRatta, who gave
mebalance, philosophy, and jokes.

Abstract
The dynamics of healthcare are shifting the patient paradigm in dramatic
ways. The former patient is now both a consumer and a customer. The
mantra of this new consumer is convenient, fast, simple, and high value.
Their expectations for healthcare are similar to what they experience in
other industries such as transportation, banking, short-stay rental housing, retail shopping online, same-day deliveries, and more. Smart mobile
devices enable the customer to conduct transactions at any place and at
any time, and without waiting in line.
Healthcare providers need to offer customer service experiences similar
to Apple, Amazon, Nordstrom, and other benchmark companies in order
to stay competitive. The mindset of the new patient-turned-consumer has
fundamentally shifted and there is no looking back.
Anyone connected to healthcare needs to learn the profiles of the
new consumer, better understand their behaviors, and comprehend their
expectations as customers who have a choice. The patient paradigm shifts
tells you everything a successful business needs to know about the powerful new healthcare consumer.

Keywords
Affordable Care Act (ACA), big data, consumer, consumerism, consumer
profile, cost of health care, customer, EHR adoption, health, healthcare,
health information exchange, health insurance, healthcare transformation, interoperability, ObamaCare, patient, patient-turned-consumer,
precision medicine, transparency

Contents
Praise for the Patient Paradigm Shiftsxi
Foreword by Alan Weiss.........................................................................xiii
Acknowledgments................................................................................... xv
ACAs Impact on Healthcare Choices..................................................... xvii
Introduction xix
Chapter 1 Transformation of Healthcare: Its About Time and
Money.............................................................................1
Chapter 2 Healthcare Joins the 21st Century: Moving from
PapertoBinary..............................................................19
Chapter 3

We Pay and Pay for Healthcare.......................................35

Chapter 4 Reframing Healthcare Delivery: My Time and

My Place........................................................................65
Chapter 5

Consumers Are Us.........................................................91

Chapter 6

Communication Gets a Facelift....................................117

Chapter 7

In Transparency Do We Trust?......................................133

Chapter 8 Right Time, Right Place: Improving Quality at the

Pointof Treatment.......................................................147
Chapter 9

The New Old: Aging Dynamically...............................165

Chapter 10 Converging Data for Better Healthcare........................175

Chapter 11 Thoughts on the Future................................................201
Appendix: Additional Resources209
Index215

Praise for the Patient

Paradigm Shifts
Judy Chan thoughtfully articulates how the flow of data and information in the Digital Age is dramatically changing the relationship between
physicians and patients, and forever altering the landscape of American
medicine. The Patient Paradigm Shift is an insightful look inside modern
healthcare and its many challenges and opportunities.
AMA CEO James L. Madara, MD
This thoughtfully conceived book covers the dramatic changes occurring
in the United States healthcare system and carefully describes the impact
on consumers and how they will seek and engage in care. It is pragmatic,
immediately applicable, and educational. Judys book helps every healthcare leader and manager understand how and why the nation is making
the essential pivot toward more patient- and family-centered healthcare,
and what they can do to prepare.
Mark Savage, Director, Health Information Technology Policy
and Programs, National Partnership for Women & Families.
This book is a must read for anyone currently employed or entering the
healthcare field as an occupation! Judy Chan has written a comprehensive
but succinct, easy to read, thought provoking and educational review of
a complex, technology driven and rapidly evolving industry. Examples
make complex subject matter easy to understand. She does an outstanding job of listing resources and recommendations for improvement in key
areas which put consumers in the drivers seat using innovative means of
technology based communication and service delivery.
Susan B. Hunt, CEO, Hawaii Island Health Information
Exchange, Project Director, Hawaii Island Beacon Community.

xii

Praise for the Patient Paradigm Shifts

Healthcare is at a critical junction in its evolution. Bringing together

patients, providers and payers will pave the way for a dynamic and
successful healthcare system. Judy Chan is providing a road map for that
journey and I suggest you attune your healthcare GPS to The Patient
Paradigm Shift to ensure success.
Richard Citrin, PhD, MBA
Healthcare and Organizational Consultant
Author, The Resilience Advantage

Foreword
Once upon a time, when I had huge hospital clients, the key was maximum bed utilization for the longest period: capitation. An empty bed was
like a missing zero on an income statement.
Today, hospitals want empty beds. Patients with hip replacements,
knee replacements (600,000 of these alone annually at this writing, twothirds for women), mastectomies, and even new mothers are virtually
thrown out of the building. Insurers dont like to pay for lengthy stays, so
empty beds are now desirable, fields awaiting new crops.
Add to this the rise of emergency rooms as personal physicians for
many, the requirement to treat indigent patients (one of my clients, a
2,000-bed facility, started every year $14 million on the hole because
of this), and tele-health, and we are watching disruptive changes before
our eyes. Its like not needing to predict when the whale will breech or the
glacier will move: its happening continually.
Central to this new equation is the healthcare consumer, who is better educated than ever, no longer willing to cower in front of doctors,
and insistent on reasonable, quality care and rapid access to services.
Its bemusing and stunning to comprehend that the vaunted Canadian
healthcare system, as an example, is slower in treating elective surgery
than are veterinarians in the United States treating dogs.
The paradigms are shiftingagain, as we watch and observe in real
timeand these new consumer attitudes are the pivot point. Judy Chan,
who has spent her entire professional life in healthcare consulting, has
splendidly profiled these present and future consumers. In The Patient
Paradigm Shift she highlights the changes required, timing, transparency
needs, and most importantly, the use of data, information, and knowledge required for high quality treatment and efficient operations.
Judy is the interpreter of and guide through these tectonic changes.
She makes effective diagnoses and prescribes original and totally appropriate courses of treatment. Her entire work is about the short-term future,

xiv Foreword

and her final chapter, extending her views even farther out, is worth the
price of the entire book.
Read on to follow this intrepid explorer of the new consumer dynamics in healthcare and how every healthcare organization can change to
meet them profitably and successfully. Not reading this carefully is like
healthcare workers not washing their hands. Its a simple act, yet one vital
to life and health.
Alan Weiss, PhD
Author Million Dollar Maverick, Million D
ollar Consulting
and over 60 other books

Acknowledgments
A big thank you to everyone who contributed to making this book about
healthcare possible.
Fellow professionalsTimi Leslie, Michael Colville, Patricia Houden,
Lyman Dennis, May Ng, Lauren Vela, Melinda Nugent, and Prashant
Natarajan, who have spent many years in healthcaregave me insights,
ideas, and suggested companies with innovative approaches.
My business consulting colleagues, Richard Citrin, Mark Rodgers,
Christian Milaster, Pam Harper, Hugh Blane, Roberta Matuson, and
Linda Popky, provided valuable feedback.
The professionals who helped me bring the book to lifeNora Isaacs
for eloquently simplifying the complicated prose, Audric Goo for the
creative illustrations on ACA, and Julie Terberg for graphics.
Thank you to Alan Weiss, whom I met after moving back from three
years in Asia. I had decided to merge my two big interests, healthcare and
technology, into a consulting practice. Hes now been a mentor and coach
to me for 15 years and I am a better consultant every day because of him.
Finally, the unwavering love and support from my wonderful husband
Ken and creative daughter Caitlin were essential to giving me the time
and focus needed to make this book possible.
Judy L. Chan, MPH
June 2016

ACAs Impact on
HealthcareChoices

Pre-Affordable Care Act: Healthcare choices for employer-insured,

Medicaid, and uninsured.

Post-Affordable Care Act: Marketplace choices for employer-insured,

Medicaid, and healthcare market exchanges newly insured.

Introduction
After 40 years of status quo in the U.S. healthcare system, the changes
that have descended on the system in the past five years have been like
speeding down the Autobahn after driving on a slow country road. Nearly
all of these changes, in one way or another, are due to the 2010 passage
of the Health Information Technology for Economic and Clinical Health
(HITECH) Act and the Affordable Care Act (ACA, and commonly
referred to as ObamaCare).
Every time I told someone I was writing a book about the healthcare consumer, without fail they would want to tell me their experiences. I learned that everyone has an opinion or personal story about
ObamaCare, the part of the ACA that has to do with individual insurance. Ive included some of the stories that illustrate the bumpy ride that
consumers have gone through during the implementation of the ACA.
A big threat to ACA came when specific wording in the law created a
question on whether individuals who purchased insurance on Healthcare.
gov were eligible to receive subsidies for their premiums. The Supreme
Court ruling in this case, King v. Burwell, decided that subsidies were
available to individuals whether they purchased insurance on a state-run
exchange or the federal marketplace, Healthcare.gov.
Even though this threat is gone, the consumer still has many questions.
The purchasers of individual health insurance are still trying to figure
out the letters from insurance companies that say their plan has been
discontinued and switched to a new plan. After all, switching plans isnt
the same as switching carsthe plans may not have the same n
etwork of
physicians and hospitals, which is usually the first thing a consumer looks
for after cost. The ride isnt over yet because some of the Acts provisions
were postponed due to intense lobbying and deal cutting in Washington,
DC. This is a presidential election year and the Republicans vow to repeal
ACA should their candidate take office. That would severely disrupt the
sensitive changing health ecosystem. The important question on everyones mind is: What would replace the ACA?

xx Introduction

Threats of repeal aside, ACA still needs to stabilize and smooth out
in many spots. While Healthcare.gov, the official state insurance marketplace for states, had a very public disastrous rollout in its first year, it has
fixed most of the problems and continues to make improvements as it finishes its third year of enrolling individual consumers. Only 13 states and
the District of Columbia have their own marketplace exchanges, while
the remainder rely on enrollment through Healthcare.gov in some way.
Oregon, Nevada, New Mexico, and Hawaii started their own state-run
exchanges, but gave up and turned over enrollment duties to the federal
exchange while maintaining responsibility for all marketplace functions.
Another casualty of fiscal cliff talks is the consumer operated and oriented plans (CO-OP) program that opened in 23 states with health insurance exchanges in 2013. The CO-OPs were created to serve rural and
harder-to-reach populations that have little coverage by employer-based
insurance. The people who initially joined the CO-OPs were expected to
be the uninsured who were sick and needed care; the people who drive up
the premiums. Some of that cost was offset by the risk-corridor program,
which gives CO-OPs financial padding to keep premium costs down.
Only 11 of the 23 CO-OPs that began in 2013 remain operational at
the beginning of 2016, mostly due to the federal cuts in the risk-corridor
program.
With widespread use of technology, consumers expectations are rapidly changing. Recently, I was on a plane to San Francisco, seated next to a
woman who worked for Intels research and development division. When
I told her that I was a consultant in healthcare information technology
and customer experience, we immediately bonded as mothers who must
interact with the healthcare system on behalf of our children. She told me
a story about her 13-year-old daughter who recently had a rash. It was the
weekend, so like many moms, she could tell it wasnt an emergency and
waited a day to see if the rash would go away on its own. When it didnt,
she called the doctors office. The nurse said that she couldnt tell from the
description what it was and she needed to bring the child in. Really?
said the mom, I can just take a picture of it and send it to you. Sadly,
the response from the nurse was, Were not equipped to handle that.
I just wanted to know whether I could buy something over the
counter in the drug store instead of taking the time to go to the doctors

 Introduction

xxi

office where they will tell me the same thing, she told me. We have
a very busy family schedule and taking two or three hours to go to the
doctors office is difficult when my daughter is not really sick. Why cant
they look at a picture and tell me what to do? She had a phone that could
take a picture and send it immediately to the advice nurse. Clearly, it was
not a technical issue to receive the photo, since any smartphone or laptop
or computer could do it. The problem was that the healthcare office did
not have a process for accepting the picture and acting on it. She was
obviously very frustrated by the experience.
It is exactly these types of consumer and patient encounters with the
traditional healthcare system that is creating the demand for new methods of healthcare delivery. Convenient, simple, and quick are the battle
cries of the new health consumer.
Healthcare needs to learn from other industry models what the
consumer wants. For example, BMW, a 100-year-old company, is making moves to get younger customers, since their average customer is
55years old. They know that many young people are more interested in
a smartphone than a car, so they decided that they needed to get future
customers into their cars in order to experience a BMW and influence
their choices when the time comes to buy a new car. They instituted a
pilot program in large cities that allows customers to pick up and drive a
BMW from a pool of cars strategically located around the city. Their aim
is for the service is to be fast, convenient, and simple. Hospitals could
try to improve the experience for consumers by checking into a hospital
online. The consumer could also be prepared for procedures using a video
walkthrough of what will happen once they walk through the hospital
doors through discharge.
The transformation of the healthcare system means that healthcare
purchases are changing from patients who go to the hospitals and labs
that their doctor recommends into retail consumers who shop for the
services that they need while keeping an eye on quality and price.
Quick, fast, and instant are not new adjectives to consumers. Why else
do we have instant oatmeal, microwave meals, and fast food restaurants?
Our cars can get an oil change at Jiffy Lube and we can check out potential suitors with speed dating. The daily lives of families and individuals
move at an increasingly faster pace in an attempt to get more done in a

xxii Introduction

day. Fast is not an adjective associated with nonemergency healthcare, but

change is on the horizon. In the past, it was faster and more comfortable
to wait for the doctor to come to our homes than to go to an emergency
room (ER) of todays hospital, where it is common to wait hours to be
seen by a physician.
This book is intended as a tool for people in the healthcare industry
trying to understand the past, present, and future of the healthcare landscape. In the first chapter, I describe the five key drivers for the shift from
patient to consumer, introduce you to the healthcare consumers profile,
and give an overview of the healthcare landscape today. The second chapter discusses the challenges that came from moving the industry from
paper to a digital system. Chapter 3 looks at how and why we pay so
much for healthcare insurance, who makes up the newly insured, and cost
shifting. The new modes for healthcare delivery including speed clinics,
my term for convenience clinics found in retail spaces, are discussed in
Chapter 4. Chapter 5 presents the Healthcare Consumer Manifesto; it is
what I believe consumers want from our healthcare system. Also included
are profiles and differentiating factors of that make up the new consumer.
In this digital age, there are many new ways to communicate with
consumers, which is discussed in Chapter 6. Transparencyand the lack
of itare covered in Chapter 7. Technologytelehealth, health information exchange, and privacyare the topics for Chapter 8. How our
aging population will be able to stay at home with the help of technology
is covered in Chapter 9.
There are a lot of data that healthcare can use from many sources now
that patient data are digital. Chapter 10 discusses hyperdata, the precision medicine initiative, predictive analytics, and a bit about qualitative
and quantitative research. The last chapter presents my thoughts of where
technology can take us in the foreseeable future.
The True Stories in the book were told to me by those who experienced the situation firsthand. As a very healthy individual, my encounters
with the healthcare system were mainly through obtaining care for my
father who was three weeks shy of 99 years old when he died. Ive added
my own stories from acting as the point person for him whenever he was
hospitalized.

 Introduction xxiii

Throughout the book, I offer practical Transformation Tips for ways

to get started moving your business to align with the new consumers
needs and expectations. These tips come from 30 years of experience in
the healthcare and technology industries. The appendix lists the URLs of
websites mentioned in the book.
Change is on the horizon to meet the demands of the new healthcare
consumer. I hope this book helps you to increase your businesss success
by preparing for the new consumer.
Although it was a challenge to stay abreast of the rapid changes in
healthcare to keep the information in this book current, it has been very
exciting to write about healthcare and its very visible transformation.

Note: I have randomly used he and she throughout the book when gender
is irrelevant.

CHAPTER 1

Transformation of
Healthcare
Its About Time and Money
It wasnt long ago that the healthcare industry was unsure of whether
to call their target audience patients or consumers. Why? Because
patients were people who used the healthcare system. Patients would
choose a health plan, but they didnt shop for healthcare services the way
customers shop in retail. Consumers shop before they buy. Its a subtle
difference in words, but a big difference in peoples behavior.
Today, there is clearly a new healthcare consumer in town. A perfect
storm of the Health Information Technology for Economic and Clinical
Health (HITECH) Act, high deductible health plans, and mandatory
individual health insurance has left the old patient in its wake and ushered
in a consumer more akin to other industries such as restaurants, clothing,
and transportation. These consumers make active decisions about where
to spend their dollars. As the healthcare system transitions to person-
centered care, it must serve both the patient and the new consumer.
There are five drivers behind the shift from patients to consumers:
1. Consumerisms rise: The consumer shares information and opinions; comes armed with knowledge; and shops for quality, cost, and
value. While the financial industry is ahead of healthcare when it
comes to customers use of technology, many new options for health
coverage and delivery have recently emerged.
2. On-demand delivery: The healthcare consumer now has more
choices available for care that meet the need for convenience, accessibility, and time efficiency.

2 THE PATIENT PARADIGM SHIFTS

3. Instant communication: Engaging patients is a goal of providers

to encourage better health and care management. Technology has
brought new methods of communication, and consumers want to
utilize the same methods of communication with their providers
as they use in other parts of their lives. Consumers expect online
appointments, social media, and e-mail as the norm, not the
exception.
4. Hyperdata: A plethora of data now accompanies the world of the
new consumer to help him make choices based on quality and cost.
Ratings of healthcare services, providers, and costs are becoming
more prevalent and shed some light on where healthcare dollars
are spent. Consumers are also contributing their own data to track
fitness and monitor health conditions.
5. Predictive analytics: Analyses of historical data of patients and their
treatments have become important to predicting the outcomes of
patients.

Changing with the TimesResistance Is Futile

The new healthcare consumer wants care that is centered on the individual. The old provider-centric, hospital-based model of care is outdated
and doesnt meet the needs of todays consumers because it lacks the
agility to adapt to fundamental changes occurring in healthcare transformation. The shift to a person-centered model means a holistic approach
to an individuals lifelong health that makes appropriate interventions
when ill and best recommendations for a healthy life that are customized
to the consumers lifestyle based on family history and genetics.1
The new consumer will look for new providers who can provide what
they seek. Connected providersdigital natives who grew up with smartphones, instant access to information on the Internet, interactive games,
and online educationwill become increasingly available for consumers
to find. This generation, Provider 2.0, will use the most recent innovations such as text, virtual visits, multiple data sources, telehealth, and data
While not scientifically proven, companies are making the service available. See
Arivale in the appendix.
1

 Transformation of Healthcare 3

sharing with the touch of a screenas the normal way to treat patients in
their new or transformed provider organizations.
Technology eliminates geographical borders of care. With changes in
laws, it will be possible to keep a doctor that you and your family like
even though you may move to another state or even another country.
The ability to have a provider continue to offer a patient care regardless of
location is the ultimate in consumer-centric care.
Although technology propels healthcare forward, the human touch
cannot be totally replaced. See how the delivery of care is changing in
Chapter 4.

Profiles of the New Consumers

Who are the new healthcare consumers? Theres no single healthcare
consumer, says Mark Savage.2 Depending on their phase of life and
their health or disease state, the consumer is looking for different things
to satisfy their needs.
The Changing Consumer Profile
Old consumer

Driver

New consumer

Passive

On-demand

Assertive

Doctor dominant, hospital

centric

Hyperdata

Person centric

Insurance paid costs; low

out-of-pocket

Consumerism

High deductibles; high

out-of-pocket

The new consumer comes in multiple flavors, and the healthcare

system must be able to satisfy these diverse consumers who have varying needs based throughout their lives. As the consumer encounters the
healthcare system multiple times, he becomes familiar with how it works,
how he gets billed, and how much care costs. Billing and cost will vary
depending upon an individuals type of insurance coverage (employer,
private individual/family, government). Unfortunately, the explanation of
benefits (EOB) and bills are undecipherable for most people, and it seems

Interview, Savage.

4 THE PATIENT PARADIGM SHIFTS

that not even the savviest customer gets used to reading or understanding
them.
There are several key characteristics that affect the need to use the
healthcare system and the consumers profile:
Age: Younger people are generally healthier and their use of
the healthcare system is low unless they have children or a
chronic condition. They are more interested in improving
their health through diet, fitness, and other lifestyle choices.
In this age range, women will have encounters for pregnancy
and men and women use the system when accidents occur.
Older adults will use healthcare services more frequently for
diagnostic tests and treatment for age-related problems.
Health status: An individual who has been an inpatient experiences nearly the entire range of clinical and business systems
from both the physician and hospital side. Consumers who
have chronic conditions have more encounters, including the
ER and skilled nursing.
Children under 18: Immunizations and preventive care keep
children in continuous view of their primary-care doctor.
They visit the doctor for childhood illnesses, although some
illnesses, such as earaches, sore throats, and allergies, can
cause more visits in some children. Their encounters are at the
outer layer of the system, because hospitalizations and elective
procedures are rare.
Insurance coverage: Insured consumers pay a premium each
month so they will feel that using healthcare services is something for which they have already partially paid. Consumers
with low deductible health insurance, co-payments, and
co-insurance are more likely to use healthcare services because
the out-of-pocket costs are lower. Insured people with high
deductible plans will think carefully about using services
because they must pay thousands of dollars out-of-pocket
before insurance pays.
Parental age: Consumers with older or infirm parents will
encounter the system on their behalf. These adult children

 Transformation of Healthcare 5

will influence and make choices for their parents care. The
services they need to select can range from procedures such
as hip replacement, treatment for chronic illness including
cancer, skilled nursing, and home care.
Understanding the different types of consumers allows healthcare providers to understand what the customers want and determine the services
to attract them.
There is a plethora of services and products for consumers that didnt
exist five years ago. This gives the consumer the power to choose what
best fits their needs and lifestyle. At the same time, many choices involve
paying for services out-of-pocket, which limits the reach to families with
higher disposable incomes and those whose coverage includes options
offered by employers. Employers may also offer wellness programs such
as smoking cessation at little or no cost because both the individual and
the employer benefit from the associated decrease in illness.
Consumers want choices and value. With passage of the Affordable Care Act (ACA), consumers have the responsibility to have health
insurance. Now that they have to pay more for their healthcare because
employers are pushing rising premium costs to the employee with an
average increase of 84 percent since 2005 and 24 percent since 2010,3
and insurance plans with high deductibles are more common, consumers
are more interested in cost and quality. So they are starting to shop for
different aspects of healthcare much like other industries. The challenge
in the healthcare industry is that the consumer does not always know
what she is purchasing, and clarity is hard to find. Here are the things that
consumers are looking for when purchasing healthcare.

The New Healthcare Consumers Shopping List

1. Value (quality/price)
2. Convenience
3. Access to different types of care
2015 Employer Health Benefits Survey (2015).

6 THE PATIENT PARADIGM SHIFTS

4. On-demand
5. Health plan that fits individual or family needs
6. Local care
7. Personalized care at all levels
8. Images that can be exchanged with other providers
9. Pharmaceuticals that are easily refilled and lower prices for the
same prescription
10. Lab tests that are lower cost with high quality
11. Elderly caremedical, gerontologist, physical therapy, skilled
nursing
12. Elderly care (nonmedical)assisted living, caregivers, social
needs
13. Health tracking aids, fitness, and diet
14. Genomic datatests for health, traits, and pharmacogenetics
15. Childrens needsmedical, sports, camps, other nonmedical
needs
16. Easy and responsive communication with providers
17. Ability to view ones own health records and correct errors

Privacy and security are not on the list because they are the price
of entry in any healthcare product and service, just like in financial
services. The Health Insurance Portability and Accountability Act of
1996 (HIPAA) is expected to manage the privacy and security aspects of
healthcare data for covered entities, but businesses who are not covered
by HIPAA need to show their rules clearly for disclosure and sharing of
their customers data. The privacy notices should be in plain language and
prominently located in their website and marketing material.

Shopping for Healthcare

The question is: How does the healthcare consumer shop? They are using
their smartphones or computers to shop online. In cases where prices are
not available online, the consumer must make a telephone call. When the
recommendation of a family or friend is requested, a call is highly likely.

 Transformation of Healthcare 7

Shopping online means reading websites, looking up reviews and

ratings, and comparing scores with similar providers or services using
various websites that provide comparative information. Theres a lot of
information available, but if one is looking for price and quality together,
the information is not often found that way. It is up to the consumer to
manually sort and compare the data from the different sites. That is not
an easy job, and is time consuming, for the shopper.
Healthcare companies are addressing this gap. A new company,
Amino, helps consumers go beyond comparing online reviews by finding doctors who fit a patients needs, preferences, and condition. Its
matching algorithm is based on age, gender, and condition. The ranking
is based on research that shows the number of patients treated for a
condition is a good predictor of medical outcomes.4 After asking questions, it then searches a database of nearly 500 billion interactions of
200 million Americans to match physicians based on the number of
people they have treated with the consumers condition and specified
preferences. To keep it seamless, after selecting a doctor, you can book
an appointment right in the same website and Amino will check to
make sure they accept the shoppers insurance. The benefits are that
doctors get new patients, the consumer knows the doctor has treated
patients with the same condition, and that the individuals insurance is
accepted by the physician.
Employers are increasingly offering options that offer access, convenience, and on-demand. This ranges from booking a telehealth (phone
or video) appointment to finding the best place to purchase prescription medications. The advantage to the employee is that the functions
are available any time on a smartphone or PC, it saves the employee the
effort of looking up information on the Internet, appointments can be
booked for televisits within 15 minutes, unproductive work time in a
waiting room is eliminated, and the employee does not have to leave his
workplace, a bonus.
The employers overall healthcare costs can go down if the employee
chooses to use the options. Many of these offerings such as Castlight
https://amino.com/how-it-works/science/calculating-your-matches/

8 THE PATIENT PARADIGM SHIFTS

(integrated view across medical, pharmacy, dental, and behavioral health

benefits that allows employees to shop for and manage their healthcare),
Oration (enables employees to manage their prescriptions and purchase
drugs at the lowest cost from their mobile devices), and Teladoc (24/7
access to a doctor by mobile app, video online, or phone call) are unknown
to the consumer and many do not have experience with them. It will take
some time to ramp up utilization of these new offerings as consumers
become more familiar and comfortable with the recommendations made
by the apps. The opportunity to use these applications will initially come
from employers for their employees, but the consumer who works for
a small employer or purchases his or her own insurance will probably
not be aware of these services unless one spends a lot of time looking on
theInternet.

How Insurance Affects Our HealthcareJust the Facts

Healthcare in the United States is paid for by private health insurance,
Medicare5 for the 65 and over population, and Medicaid for low-income
people. Medicare and Medicaid are funded by federal and state monies, and as the largest payers, set the rules for reimbursements of services
and procedures that private insurers generally follow. A growing wave
of Medicare beneficiariesapproximately 7,000 to 10,000 per day are
turning 65 years oldmakes Medicare the second largest single payer of
healthcare after Medicaid.
The healthcare payment model has always been fee-for-service, where
the volume of fees increases total payments. Since the system did not
penalize for duplicate lab tests or images when results were not readily
available to share between physicians, tests were often ordered repeatedlyunless they were faxed. Thats because, in the past, adoption of
EHRs was low prior to the HITECH Act incentives and faxing was the
primary means of communicating patient information from one provider
to another.

Medicare also covers certain young people with disabilities and people with
End-Stage Renal Disease (ESRD).
5

 Transformation of Healthcare 9

Patients are the ones who have suffered from the lack of digitization of
medical records in hospitals and physician offices. Insurance pays for the
duplicate tests, but patients still had to pay co-pays and needed to take
time to schedule the tests and endure additional bodily exposure to needles, scans, and other diagnostic procedures. Some patients with illnesses
that covered years of medical treatments had to physically carry around
their medical records to their many doctor appointments for specialist
care or second opinions. Today, in spite of 90 percent of hospitals with
EHRs and 65 percent of physicians with EHRs, patients still find themselves carrying around paper copies of medical records spit out by EHRs
and full-size film images that cant be read by a different providers system.
Thats because EHRs cant talk to one another, a huge problem that is just
starting to get addressed across the industry.

True Story
Lack of Interoperability Burdens the Consumer
Noah is a boy who lives in the San Francisco Bay Area and has severe
scoliosis, a sideways curvature of the spine. His parents counseled with
many specialists over the years to determine what would be the best
course of treatment and when. Given the severity of the spines curvature, surgery was inevitable. Since he was seven years old, the orthopedic
spine surgery group at Sutter Hospital in Sacramento monitored him
and kept his medical records in their EHR. In 2015, prior to his surgery, the endocrinology department at Stanford Medical Center evaluated Noah so his parents could determine if he should have growing
rods (that need to be adjusted every six months) or a final spine fusion.
It was a big decision, and the records were vital to informing the endocrinology department, along with the additional tests they performed.
It was impossible to transfer the records electronically between
the two hospitals even though both used Epic as their EHR system.
The parents had to hand-carry records on CDs and outsized images
ofthe spine from Sacramento to Stanforda three-hour car drivein
order to share the information with the Stanford team. According to
Noahs mother, It was a huge hassle, plus it extended the time before

10 THE PATIENT PARADIGM SHIFTS

we could schedule the evaluation appointment, which pushed out the

date for surgery. After that, we had to manually get the endocrinology records (multiple tests including blood, x-ray and MRI) back to
Sutter. Sutter and Stanford are two large well-known medical facilities
in northern California that have the state-of-the-art medical record
systems. Yet, they couldnt exchange data with each other even though
they had the same EHR.

At the June 2015 annual Office National Coordinator (ONC) meeting, the Office of Civil Rights (OCR) made clear that patients had the
right to request that their healthcare information be transmitted to a
third party such as family, an application on a mobile device (app), or
another organization. In Noahs case, the problem was that the same Epic
EHR software could not send and receive the data in a useful manner
at another healthcare institution. This is a peek into the interoperability
issue covered in Chapter 2.
Insurance coverage has vastly changed with the 2010 passage of the
ACA.
Now health insurance is mandated for all,6 and individuals must
purchase insurance if it is not provided by their employer and the individual is not eligible for Medicare. The ACA also expanded eligibility for
Medicaid coverage of low income individuals to purchase insurance. The
new requirements for insurance coverage caused health insurers to c reate
new plans and remove plans whose coverage was not compliant with the
ACA. The federal requirement that everyone be covered by insurance
also triggered a series of changes, including the features that health plans
offered and critical consumer protections.
Under the law, a new Patients Bill of Rights gives the American
people the stability and flexibility to make informed choices about their

Exceptions include religious reasons, Native Americans, incarceration, and

other categories. Illegal aliens are excluded from the ACA requirement.
6

 Transformation of Healthcare 11

health. The Patient Bill of Rights, shown below, was implemented six
months after the ACA was passed in 2009, and it put an end to some of
the worst abuses of health insurance policies.

A New Patients Bill of Rights

These new protections7 include:
Ban on Discriminating Against Kids with Preexisting
Conditions
Before reform, tens of the thousands of families have been denied
insurance each year for their children because of an illness or condition.
With the Patients Bill of Rights, plans cannot discriminate against
kids with preexisting conditions. In 2014, no one seeking coverage
could be discriminated against because of a preexisting condition.
Ban on Insurance Companies Dropping Coverage
Before reform, insurance companies could cancel your coverage when
you were sick and needed it most because of a simple mistake on your
application. With the Patients Bill of Rights, insurance companies are
banned from cutting off your coverage due to an unintentional mistake on your application.
Ban on Insurance Companies Limiting Coverage
Before reform, cancer patients and individuals suffering from other
serious and chronic diseases were often forced to limit or go without
treatment because of an insurers lifetime limit on their coverage. With
the Patients Bill of Rights, insurance companies can no longer put a
7

Affordable Care Act, www.hhs.gov/healthcare/about-the-law/

12 THE PATIENT PARADIGM SHIFTS

lifetime limit on the amount of coverage, so families can live with the
security of knowing that their coverage will be there when they need
it most. The use of annual limits will be restricted and will be banned
completely in 2014.
Ban on Insurance Companies Limiting Choice of Doctors
Before reform, insurance companies could decide which doctor you
could go to. With the Patients Bill of Rights, if you purchase or join a
new plan you have the right to choose your own doctor in your insurer
network.
Ban on Insurance Companies Restricting Emergency
RoomCare
Before reform, insurance companies could limit which emergency
room (ER) you could go to or charge you more if you went out of
network. With the Patients Bill of Rights, if you purchase or join a
new plan, those plans are banned from charging more for emergency
services obtained out of network.
Guarantee You a Right to Appeal
Before reform, when insurers denied you coverage or restricted your
treatment, you were left with few options to repeal. With the Patients
Bill of Rights, if you purchase or join a new policy, you will be guaranteed the right to appeal insurance company decisions to an independent third party.
Covering Young Adults on Parents Plan
With the Patients Bill of Rights, young adults will be allowed to
remain on their parents plan until their 26th birthday, unless they are
offered coverage at work. Up to 2.4 million young adults could gain
affordable coverage through this provision of the new law.

 Transformation of Healthcare 13

Covering Preventive Care with No Cost

With the Patients Bill of Rights, if you join or purchase a new plan,
you will receive recommended preventive care8 with no out-of-pocket
cost. Services such as mammograms, colonoscopies, immunizations,
prenatal, and new baby care will be covered and insurance companies will be prohibited from charging deductibles, co-payments, or
co-insurance.
These patient rights protect the consumer from some of the most common insurance company practices that discriminated against c onsumers.
The two rights that will impact most consumers are: (1) preexisting
conditions cannot be used to discriminate by charging higher premiums,
denying coverage, or dropping coverage when ill and (2) preventive care
with no out-of-pocket costs. Patients who engage in preventive services
are more likely to catch anomalies early, making treatment more effective
and less costly.
Every consumer has a right to obtain health insurance that does not
cost more than a similar individual because he has a condition. This
should be a comfort to healthy individuals because insurance companies
cannot drop members just because theyve been diagnosed with a condition that requires expensive or long-term treatments.

Impact of High Deductibles

The growth of high deductible plans is transforming the healthcare
market into a retail market. Now, lab tests and imaging are commodity
services that can be shopped by price, and retail pharmacies and standalone emergency and urgent care facilities offer services that compete with
traditional providers.
The average deductible for an employer-sponsored plan in 2015 was
$1,318, while health insurance exchange plans deductibles averaged from
Preventive services covered under the Affordable Care Act, www.hhs.gov/
healthcare/facts-and-features/fact-sheets/preventive-services-covered-under-aca/
8

14 THE PATIENT PARADIGM SHIFTS

$484 for platinum to $5,724 for bronze plans.9 Exchange plans have high
deductibles at the silver and bronze tiers and individuals purchasing these
plans are eligible to receive financial assistance from Medicaid to pay for
premiums. Out-of-pocket costs for premiums and deductibles have doubled to nearly 9.6 percent of household income between 2003 and 2013,
according to data from the Commonwealth Fund.
It is too early to conclusively determine whether high deductible plans
will affect payments to providers. Some providers such as St. Lukes Health
System in Kansas City, Missouri, have introduced pre-payment policies
for self-pay patients as well as those who will owe more than $1,000 or
20 percent of the cost of their procedure. St. Lukes provided estimates
for care to all 26,000 patients in 2011 in the belief that if a patient knows
what they might owe, they are more likely to make a payment.
With high deductible plans, patients will carefully consider whether
to proceed with elective treatments or delay them. Providers can help by
making payment plans and financing options available to patients when
they seek treatment.
Another payment model being tried by employers such as Lowes offers
all employees surgeries for free. The catch is that the care must be at one
of the select prestigious hospitals around the nation that has a bundled
payment rate with Lowes. Lowes pays one flat rate for the surgery, physical therapy, and potential complications within a given timeframe. The
company has saved money even after paying for employees travel. Pacific
Business Group on Health (PBGH) negotiates the bundled payment for
Lowes and several other large employers.
The third round of health insurance for coverage in 2016 offered
under the ACA took place as this book was being written. Insurers have
boosted premiums for the most popular plans while increasing out-ofpockets costs such as co-pays, co-insurance, and deductibles at the same
time. Other insurers have joined the insurance marketplaces as some
dropped out due to losses from the exchange market business. Consumers
who shop on the health exchanges are finding that it is difficult to avoid
premium increases. Less-expensive plans mean less coverage and smaller

Gabel et al. (2016).

 Transformation of Healthcare 15

networks of doctors that may not include a consumers local doctors. Prior
to the opening of the federal market exchange, premiums for individual
plans by dominant local insurers were increasing by 10 percent or more
in 30 states covered by Healthcare.gov, the federal insurance exchange,
according to an analysis by the Wall Street Journal.
High deductibles may spur new healthcare businesses as the consumer
is looking for high-quality care at a fixed price while minimizing out-ofpocket expenses for an individual or family. Healthcare services offered
in retail outlets and telehealth visits would benefit the consumer who is
trying to avoid high out-of-pocket expenses. The health insurers need to
keep healthy people in their plans in order to avoid only insuring and
paying for the expensive unhealthy people. An insured pool of individuals
must contain people whose combined care costs less than their premiums.
Yet, it is difficult to accomplish keeping healthy individuals in the pools
when premiums increase and deductibles go up. Moving forward, health
insurers selling to individuals will need to find creative ways to attract and
keep young healthy consumers in their plans.

Transformation Tips: How Providers Can Attract

theNew Consumer and Keep the Ones They Have
Offer access to schedule appointments, refill prescriptions, and ask
questions via mobile devices and patient portals.
Give patients more information about their financial responsibilities before treatment.
Provide cost estimates and education about cost of services.
Publicize estimated prices.
Educate consumers at nonclinical settings.
Set up financing options and payment plans for patients.
Be able to electronically exchange patient information with other
providers.

Changing with the TimesResistance Is Futile

The whole paradigm of healthcare is shifting. The long-standing fee-forservice model is being replaced by bundled or episodic care models. While

16 THE PATIENT PARADIGM SHIFTS

fee-for-service has promoted volume over outcome of care to the detriment of the patient, the new models are very different because the fee is
based on care for a specified episode of illness and covers all care received.
One new and promising model is the Accountable Care Organization (ACO), which is when close partnerships are formed with the
idea that costs can be more controlled with partners or within a single organization. An ACO is a network of doctors and hospitals that
shares responsibility for providing care to patients. In the new law, an
ACO would agree to manage all of the healthcare needs of a minimum of
5,000 Medicare beneficiaries for at least three years. ACOs were created
to change the incentives for how medical care is paid for in the United
States, moving away from a system that rewards the quantity of services
to one that rewards the quality of health outcomes. ACOs are paid on the
basis of the success of the treatment administered, not on the volume of
tests and procedures performed. This new model includes the ability to
share patient information, which is crucial to seamless transitions of care
among the network.
Another change is the recent growth in EHRs, which has occurred
at the hospital and physician level. In 2014, 75 percent of hospitals
(Figure1.1) and 82 percent of office-based physicians (Figure 1.2) had an
EHR compared to nine percent and 42 percent, respectively, in 2008. So
far, the implementation has not crossed over to skilled nursing and other

Figure 1.1 EHR adoption among U.S. hospitals, 20082014

Source: Adler-Millstein et al. (2014); Charles, Gabriel, and Searcy (2015) (Authors calculations).

 Transformation of Healthcare 17

Figure 1.2 EHR adoption among U.S. office-based physicians,

20082014
Source: National Center for Health Statistics. NAMCS EHR Supplement, 2014.

non-acute care facilities to make the information exchange electronic

instead of paper. In order to reap the benefits of bundled payments, the
efficiency of electronic records must be implemented at all levels of care.
The Centers for Medicare and Medicaid services (CMS) are moving
to change the fee-for-service model to value and outcome-based payments. In November 2015, CMS announced that fees for knee and hip
replacement surgeries would be bundled into one payment for the hospital stay and all care for 90 days afterward beginning in April 2016. CMS
initiated a demonstration project after finding fees ranged from $16,500
to $33,000 for replacements of hips and knees, the most common procedures that Medicare beneficiaries receive. The five-year demonstration
project is expected to save Medicare $153 million over the duration. The
goal is to reduce spending without reducing quality, and improve patient
care without increasing spending, and all 67 geographic areas across the
country are included in the new payment model.
This is one of the first steps by the government to move away from
fee-for-service toward value-based careand to hold the institutions
providing care accountable for quality. Now the consumer can look
up provider quality and decide where to be treated and by whom,
instead of relying on just the doctors recommendation or whats in the
neighborhood.

18 THE PATIENT PARADIGM SHIFTS

All of these changes mean that the patient profile of the past is morphing into a new one, where the individual is now a consumer, customer, and
patient all merged into one. This new consumer will shop for high-quality
care with good value, will expect to be able to communicate in multiple
ways with providers, and be informed and engaged in his own health.

References
2015 Employer Health Benefits Survey. 2015. Kaiser Family Foundation.
http://kff.org/health-costs/report/2015-employer-health-benefits-survey/
Adler-Millstein, J., C.M. DesRoches, M.F. Furukawa, C. Worzala, D. Charles,
P.Kralovec, S. Stalley, and A.K. Jha. 2014. More than Half of U.S. Hospitals
Have at Least a Basic EHR, But Stage 2 Criteria Remain Challenging for
Most. Health Affairs 33, no. 9, pp. 166471.
Advisory Board. April 2016. Lowes Offers Its Employees Free Surgeries. But
Theres a Catch. www.advisory.com/daily-briefing/2016/04/27/lowes-offersits-employees-free-surgeries
Charles, D., M. Gabriel, and T. Searcy. 2015. Adoption of Electronic Health
Record Systems Among U.S. Non-federal Acute Care Hospitals 20082014.
ONC Data Brief, no. 23. Office of the National Coordinator for Health
Information Technology: Washington, DC.
Gabel, J.R., M. Green, A. Call, H. Whitmore, S. Stromberg, and R. Oran. May
12, 2016. Changes in Consumer Cost-Sharing for Health Plans Sold in the
ACAs Insurance Marketplaces, 2015 to 2016. The Commonwealth Fund.
Savage, M. Director of Health Information Technology Policy and Programs, National
Partnership for Women & Children (Interview on November 9, 2015).

Index
Accountable Care Organization
(ACO), 16, 23
Accreditation Council for Graduate
Medical Education, 107
ACO. See Accountable Care
Organization
admission-discharge-transfer (ADT),
152
Affordable Care Act (ACA), xix, 35,
201
health insurance and, 5
history of, 37
impact on healthcare choices, xvii
aging consumers
technology and, 172173
transformation tips, 174
AirBNB, 95
algorithms, 192193
Allscripts, 27
AMA. See American Medical
Association
Amazon, 177
American Medical Association
(AMA), 36, 205
American Recovery and Reinvestment
Act (ARRA), 20
American Well, 74
American Well 2015 Telehealth
survey, 82
Anthem, 160
Anthem Blue Cross, 39
Application Programmatic Interfaces
(APIs), 20, 118
Argonaut Project, 26
ARRA. See American Recovery and
Reinvestment Act
athenahealth, 27
AT&T, 106
attacks, big data, 177178
Baby Boomers, 165
Bennett, Russ, 105

big data
3Vs of, 176
attacks, 177178
definition of, 175176
in healthcare, 177
used in industries, 177
Big Data (Mayer-Schnberger and
Cukier), 176
Blue Shield of California, 39
Brown, Jerry, 61
California Healthcare Foundation
(CHCF), 150
cancer, 196
cardiopulmonary resuscitation (CPR),
173
Carequality, 27
case studies
health information exchanges
(HIEs), 157158
health insurance, 52, 5455
PSRO, 134
technology, 170, 171
transformation of healthcare,
910
Castlight, 7
Centers for Disease Control and
Prevention (CDC) Statistics
& Surveillance, 106
Centers for Medicare and Medicaid
services (CMS), 17, 59, 138
Cerner, 23, 27
Chan, Eddie, 106
CHCF. See California Healthcare
Foundation
Chino Valley Medical Center in
Chino, 31
CHINs. See Community Health
Information Networks
CJR model. See Comprehensive Care
for Joint Replacement model
Clearhealthcosts.com, 136137

216 Index

CMS. See Centers for Medicare and

Medicaid services
CMS Compare (website), 141
CommonWell Health Alliance, 27
communication, 117131
curating and controversy, 121122
engagement with doctor and,
120121
information and, 121122
multiplechannels for, 129130
patient engagement and, 117119,
167
patient portal (website), 129130
physician-patient interactions,
119123
social media, 123127
text and e-mail, 127128
transformation tips, 122123
Community Health Information
Networks (CHINs), 151
community-level HIEs, 159
Comprehensive Care for Joint
Replacement (CJR) model,
138
consumer diversity, 103107
consumer engagement
hyperdata, reasons to harness,
182183
consumerisms rise, 1
consumer operated and oriented plans
(CO-OP) program, xx
consumer profiles, new, 100102
changeling, 101102
indifferent, 102
progressive, 101
tips for using, 102103
Consumer Reports (website),
140141
consumers profile, changing, 36
age, 4
children under 18, 4
health status, 4
insurance coverage, 4
parental age, 45
correlations, data, 190191
Covered California, 61
CPSI, 27
Cukier, Kenneth, 176
customer satisfaction, 108

customer satisfaction research, 180

cyberattacks, 3033
cybersecurity risks, 3233
data
blocking, 150
collection, 104
correlations, 190191
Davids versus Goliaths, 184187
de-identification of, 161
digital healthcare, 175
hyperdata and analytics, 194
making meaningful, 180181
ownership, 193194
reasons to harness hyperdata,
181184
security and integrity, 150
security, 193194
sensitivity, 150
super-sized, 175177
Davids data versus Goliaths data,
184187
Department of Health and Human
Services (HHS), 79, 133
Desert Valley Hospital of Victorville,
31
digital healthcare data, 175
super-sized data, 175177
Doctor on Demand, 74
doctor-patient relationship, 109
do-it-yourself (DIY) health for future,
202204
eBay, 160
eHealth Exchange, 26
EHRs. See electronic healthcare
records
EHR Incentive Program, 103
EHR Meaningful Use Incentive
program, 103
electronic bedside manner, 119120
electronic healthcare records (EHRs),
2023
adoption of, 151
application programming interface
(API), 118
consumers trust with, 9495
cyberattacks and, 3033
cybersecurity risks and, 3233

 Index 217

functionality and features in, 94

Incentive Program payments,
2223
interoperability, 2326
meaningful use, defined, 21
meaningful users, 2122
online access to, 9495
physician bedside manner, 119120
rise of, 9495
significant value in, 94
switching from paper to, 2023
e-mail
communication, 127128
security, 128
exabytes (1018), 176
Facebook, 161
Fast Healthcare Interoperability
Resource (FHIR), 20, 2728,
118
FDA. See Food and Drug
Administration
Federal Communication Commission
(FCC), 79
Federal Trade Commission (FTC),
79
FHIR. See Fast Healthcare
Interoperability Resource
Fitbits, 178
Flexible Savings Account (FSA), 76
flow of information, 2930
consumer access, 2930
no information blocking, 30
standards, 30
Food and Drug Administration
(FDA), 60, 79
FSA. See Flexible Savings Account
FTC. See Federal Trade Commission
GAO. See Government Accountability
Office
Gene2Gene, 111
Generic Pharmaceutical Association,
61
gigabytes (109), 176
Google, 177
Government Accountability Office
(GAO), 5, 25
Greenway, 27

GrubHub, 95
Guroo (website), 137
HCCI. See Health Care Cost Institute
healthcare, transformation of, xx,
118
case studies, 910
changing with time, 23, 1518
deductible plans, 1315
drivers of, 12
insurance and, 813
Patient Bill of Rights, 1113
shopping for, 68
tips, 15
Healthcare Bluebook, 137
Healthcare Consumer Manifesto,
9192
healthcare consumers
attracting, 9697
choices and value, 5
communication and, 117131
cost shifting to, 4951
guidelines for treating, 108109
manifesto, 9192
needs, 47
NEMS story, 105107
new mindset and behavior,
110111
newly insured, 47
online rating systems and, 139145
patient paradigm shifts, 109114
patient-turned into, 97102
shopping list, 56
transformation tips, 115116
understanding new, 9297
view of health insurance, 45
healthcare delivery, reframing, 6589
consumer demands, 93
house calls encore, 8788
less hassle and better care, 6770
technology-enabled model for
primary care, 6970
traditional concierge-based care,
6869
speed clinics, 7074
telehealth, 7684
traditional primary doctor
challenges, 66
transformation tips, 88

218 Index

transforming, 6667
virtual care on demand, 7476
healthcare ecosystem, 114115
Healthcare.gov, xx, 201
healthcare in 21st century
faxes and, 19
incentives to convert paper records
to EHRs, 2023
healthcare industry
big data in, 177
do-it-yourself (DIY) health for
future, 202204
future of, 201207
perpetual transformation in, 201
qualitative and quantitative research
in, 178180
healthcare payment model, 813
healthcare professionals
electronic black bag, 114115
healthcare systems, hacking of, 31
healthcare tools, 118
health disparities
action plan for reducing, 103104
NEMS patients and, 106
Healthgrades (website), 139140
Health Information Exchange
Organizations (HIOs), 151
health information exchanges (HIEs),
147
assessment of state, 153
as the term, 150151
benefits for, 149
case studies, 157158
consumers, 154155
health data security and privacy,
161163
HITECH Act, 148150
meaningful use and, 152153
obstacles for, 149
privacy rule, 159160
privacy rule and, 159160
privacy transformation tips, 163
sharing involves risks, 160
survivability and sustainability,
155158
types of, 159
Health Information Technology for
Economic and Clinical Health
(HITECH) Act, xix, 1, 8, 21

health insurance
case studies, 52, 5455
consumer needs, 4749
consumers view of, 45
exchange marketplace plans,
4447
new consumers, 47
paying for uninsured, 41
premium versus deductible, 46
prescription drugs, cost of, 5963
problem with, 3842
quagmire, 5156
reality of, 3537
requirements of, 4344
risks in, 38
self-selection, 39
spending for, 38
Health Insurance Portability and
Accountability Act of 1996
(HIPAA), 6
HealthMine, 81
Health Savings Accounts (HSA), 76
health status, 99
Health Tap, 74
Heartland Payment Systems, 160
hepatitis B during pregnancy,
106107
Hepatitis C drugs, 5960
HIEs. See health information
exchanges
HIPAA
privacy rule, 159160
violation, 160
Hispanic Americans, 105
HITECH Act, 148150
Hollywood Presbyterian Medical
Center in California, 31
hyperdata, 2
hyperdata,
reasons to harness, 181184
advancing population health,
183184
consumer engagement, 182183
internet of things (IoT), 182
potential for precision medicine,
183
reducing cost of healthcare, 183
IBMs Watson computer, 113, 177

 Index 219

Information. See also health

information exchanges
and communication, 121122
flow of, 2930
health data security and privacy,
161163
instant communication, 2
insurance and healthcare, 813. See
also health insurance
insured consumers, 99
insurers, ACA and, 5658
internet of things (IoT), 182
internet review, 124125
interoperability, 2326, 150
governments big bang for, 2932
infrastructure, creating, 2832
standardization to, 29
investment in social media, 126
Kaiser, 39, 59, 62, 78
e-mail system in, 128
King v. Burwell, xix
kiosks, 7273
Kudzu, 125
Latino Solutions, 105
Leapfrog Group, The (website), 139
Lee, Tom, 6970
Madara, James L., 205
Manhattans Lenox Hill Hospital, 31
marketing return on investment
analysis (MROI), 179180
Mayer-Schnberger, Viktor, 176
McGregor, Carolyn, 189190
McKesson, 27
MD Live, 74
Medicaid, 8, 22, 35
medical apps for Android, 86
Medi-Cal insurance program, 62
medical tourism, 112113
Medicare, 8, 22, 35
mHealth = mobile, masses, motivated,
8487
mobile health (mHealth), 78
National Business Group on Health
survey (2015), 81

National Institutes of Health (NIH),

196
National Labor Relations Board,
36
Nationwide Health Information
Network (NHIN), 26
NEMS. See North East Medical
Services
Netflix, 161
NextGen, 23
NHIN. See Nationwide Health
Information Network
NIH. See National Institutes of
Health
nonemergency care, 73
North East Medical Services (NEMS),
105107
ObamaCare. See Affordable Care Act
(ACA)
Office National Coordinator (ONC),
10
Office of Civil Rights (OCR), 10
Office of the National Coordinator
for Health Information
Technology (ONC), 20, 147
on-demand services, 1
characteristics of, 97
popularity of, 97
One Medical, 6970
online rating systems
quality and cost, 141143
transformation tips, 145
transparency in, 139145
online shopping, 7
Oration, 8
Pacific Business Group on Health
(PBGH), 14
patient-centered care, 9495
patient connection with social media,
125126
patient engagement, 99100, 117
CMS requirements for, 118119
communication and, 167
meaningful use (MU) requires,
118119
patient paradigm shifts, 109114
demands, 111112

220 Index

new mindset and behavior,

110111
next generation models, 113114
patient portal (website)
communication through, 129130
transformation tips, 130
Patients Like Me (website), 125
patient-turned to healthcare
consumers
consumer profiles, 100102
consumers activism, 9899
consumers connected online, 98
health status, 99
insured consumers, 99
level of income, 100
patient engagement, 99100
value-oriented consumers, 98
PBGH. See Pacific Business Group on
Health
perpetual transformation, 201
Physician Orders for Life-Sustaining
Treatment (POLST), 173
physician-patient interactions,
119123
POLST. See Physician Orders for LifeSustaining Treatment
Post-Affordable Care Act, xvii
Pre-Affordable Care Act, xvii
precision medicine, 111
future of, 197199
initiative, 195197
new path, 195
objectives of, 196197
potential for, 183
privacy protections, 196197
public-private partnerships, 197
regulatory modernization, 197
transition tips, 199
predictive analytics, 2
basics, 188189
moving from universals to
individuals, 191193
success of, 193
technology and, 187
transformation tips, 194
preferred-provider-organization
(PPO) plans, 57
prescription drugs, price of, 5963
price of prescription drugs, 5963

price transparency, 137141

primary care physician
behavior modification in, 143144
educating patients, 121
resetting mindset about old,
169172
Prime Healthcare Services, Inc., 31
proactive consumer, 9899
Professional Standards Review
Organizations (PSROs), 134
ProPublica (website), 140
protected health information (PHI),
31
PSROs. See Professional Standards
Review Organizations
public-private partnerships, 197
Qualitative/quantitative research,
178180
quantitative tools
discrete choice analysis, 179
marketing return on investment
analysis (MROI), 179180
reactive consumer, 9899
Regional Health Information
Organizations (RHIOs), 151
remote patient monitoring (RPM), 78
research
customer satisfaction, 180
qualitative/quantitative, 178180
segmentation, 180
ResearchKit, 199
RHIOs. See Regional Health
Information Organizations
risks
cybersecurity, 3233
in health insurance, 38
in sharing data and personal
information, 160
RPM. See remote patient monitoring
Santa Barbara Care Data Exchange
(SBCDE), 150
Savage, Mark, 103
SBCDE. See Santa Barbara Care Data
Exchange
security, e-mail, 128

 Index 221

segmentation research, 180

self-selection, 39
Sequoia Project, 26
smartphones, 95, 104
social media
communication, 123127
as friend, 126127
internet review, 125
investment in, 126
patient connection, 125126
transformation tips, 127
Sony, 160
speed clinics, 7074
advantages of, 7374
importance of, 74
types
kiosks, 7273
shared retail clinics, 7172
Stabilization Act, 36
State HIE Cooperative Agreement
Programs, 151
state-level HIEs, 159
statistical methods, 187188
Sunquest, 27
super-sized data, 175177
teams electronic black bag, 114115
technology
case studies, 170, 171
design and usability of, 103
enabled model for primary care,
6970
monitoring, 167169
old folks and, 166167
predictive analytics uses, 187
resetting mindset about old,
169172
special care and, 173174
support, 172173
Teladoc, 8, 74
telehealth, 7684
defined, 77
downsides and upsides of, 8082
future of, 8384
telemedicine
modalities of, 7778
payment and, 7980
terabytes (1012), 176
Text4Baby (app), 127

texting, 127128
Thomas Jefferson University Hospitals
(Amwell), 76
T.J. Maxx, 160
traditional concierge-based care,
6869
transformation tips
aging consumers, 174
communicating with patients,
122123
consumer focused healthcare, 56
cybersecurity risks, 3233
for insurers to reduce costs, 58
online rating systems, 145
patient portals, 130
predictive analytics, 194
precision medicine, 199
privacy, 163
providers attracting new consumers,
15
reducing price of prescription
drugs, 63
social media, 127
telehealth, 88
on transparency, 145
transparency in healthcare,
133145
finding provider scores and star
ratings, 139141
lack of, 135137
price, 137141
PSROs and, 134
quality and cost, 143145
23andMe, 111
Uber, 95
UCLA (LiveHealthOnline), 76
UHClatino.com, 105
uninsured
characteristics of, 4142
paying for, 41
UnitedHealthcare, 105
University of Arizona Health
Network, 23
University of Missouri, 165
University of Ontario, 189
University of Texas, 161
U.S. Department of Veterans Affairs,
62

222 Index

value-oriented consumers, 98
variety, 176
velocity, 176
veracity, 176
videoconferencing, 78
virtual care on demand, 7476
benefits of, 75
insights, 76
virtual health visits, 8182
volume, 176
Wall Street Journal, 15
Walmart, 72
website

CMS Compare, 141

Consumer Reports,
140141
Healthgrades, 139140
Leapfrog Group, The, 139
ProPublica, 140
Yelp, 141
www.cahealthcarecompare.org,
135136
Yelp (website), 125, 141
yottabytes (1024), 176
zettabytes (1021), 176