positive deviance: innovative responses to healthcare reform

Positive Deviance: Innovative Responses to Healthcare Reform

Dr. Rick Cartor, Director, ChD, LLC HR/OD Consultant @ BB&T Insurance

Louisville, KY

http://rickcartor.wordpress.com 1


1. Outline and Goals2. The HCR context3. Key Player Responses: Payers, Providers, Users4. Users: Obstacles to Innovation

– Overcoming the Obstacles



NOT-a thorough review of PPACA-a debate on PPACA merits-a how to for specific mandates-a how to for being deviant


The GOALS of this session are: 1. understand how key players are responding to healthcare

reform so employers can find ways to survive and thrive2. enable participants to recognize and overcome common

obstacles to innovative solutions in healthcare benefit design.

Positive Deviance

…the observation that in any community, there are people whose uncommon but successful behaviors or strategies enable them to find better solutions to a problem than their peers, despite facing similar challenges and having no extra resources or knowledge than their peers.


E.g.: Malnourished children Viet Nam; Pregnancy in Uganda, Hand washing (MDs) From: Positive Deviance, Appreciative Inquiry, Switch, Checklist Manifesto

“Necessity is the mother

of invention.”

There are many in thissimilar situation

Resist the tendency to act alone


-exceptional complexity -ongoing requirements-a likely increase in costs -ambiguous terms -unique exceptions -shifting deadlines -penalties for errors-few (or no) experts -increased auditing

The “Similar Challenge”

But not identical!

States “high quality affordable care”

SOLUTIONS VARY….• Population (size, demographics)• Geography (size, concentration) • Politics / philosophy re: state/fed • Economic condition• Healthcare history (current status) • Healthcare governance and regulations • Insurance laws / regulations• Penchant for Innovation

The “Similar Challenge”

But the key players remain the same – and

are each adapting

7

$-Payer

+ Provider User / group

8

$-Payer

Diversify:New products / M&A• stop loss; level premium• ASO/TPA• Data salesMedical management• IT services (exchanges)• Wellness programs• Care & Clinics• Telemed / kiosks• DM

Retail:• Indiv / small group• 90+% covered• 50% fewer via broker• ¾ direct to consumer• Bare minimum / EB• States’ M&M

Cost:1. Relationshipsa. Provider focused:

• Collab w providers• Shift risk: Pay for Perf

• Outcome based• ACOs / Med Homes

• Narrow Networks

b. Member focused:• Modify behaviors

PreventiveTransparencyRx tiers2. Admin costs

• Technology: Auto enroll; • adjudication, portals

• Simplify for exchanges• Outsource / offshore

2011 2019Not covered 49 27 -22Medicaid 48 59 +11Medicare 48 60 +12Individual 18 31 +13Employer 145 157 +12Total 308 334 +26

Younger, more male & whiteLess obese, more smokers & drinkers

11

+ Provider

Quality, Cost OutcomesDirect Employer contactPopulation management ACO / PCMH/ PCP nets On site clinics Managed Care / Integrated carePhysician practices Networks, narrowPhysician extenders / PA

Related Diversific• Wellness• Biomets • Lab work• Targeted DM• TPA• HCIT• EAPs

New entrants: WalMart, mini-clinics, Primary Care clinics,Wellness & biometrics,MD2U, DM,Labs (franchises!)

12User / group

FTE/PTE: hours

INCREASE PREVENTIONEncouraging Essential benefitsWellness

Premium incentives for employees

Carrot / stickRewards for P’ then resultsdrawings vs. rewardscontestsOnsite coaches (w + DM)

Chronic costs/ non-adherenceOn site near site / shared solo clinics

Primary care externedersReduce ICC & ER

Telemedicine and KiosksMedical homesPolicies / Reward redesigns

Hiring practicesfood on site, fit bits, clubs,On site fitnessRewards for PCPDEPENDENT AUDITSPURCHASING COALITIONSTRANSPARENCY TOOLS

ATTN TO PROVIDERS AND PAYERS

PROVIDER CONCESSIONSPremium rebates Premium discounts (W, PCC, etc)Related discounts (LTD for PCC)TPA/ASOSelf-funding Lower stop loss (spec/agg)

Level premium

PARTNERSHIPSConsultants v brokerData demands analyticsManaged care / Population

management / ACO BC3Inpatient Care:

Narrow networks, tiers, steerPass through Rx; tiers, incentives

mail, generics, partner, unbundle

COMMUNITY RATING: associations, captives; private exchanges

<4950-100101+


15 MISTAKEN Beliefsthat KILL innovative healthcare benefit

design within

Beliefs and Assumptions about:

(A) Healthcare in general(B) How to find a solution(C) How to implement a solution

User groups


1. U.S. healthcare is unfixable2. There are no good solutions3. Healthcare decisions are separate from…4. SSDD

MISTAKEN BELIEFS & ASSUMPTIONS ABOUT…

(A) HEALTH CARE IN GENERAL


5. In bounds & out of bounds6. Criteria: unclear, unstated, assumed...7. We have to think in 12 month cycles8. We have to settle for insufficient data9. We have no partners - but many adversaries10. “Innovative” = high risk

• Uncommon, Fast Follow, Early Adopter, 11. Things will settle down soon…one answer


(B) HOW TO FIND A SOLUTION


12. I will never be able to convince...13. It won't work here / for us because... 14. We already…15. We tried that one time...

I don’t have the time


(C) IMPLEMENTING THE SOLUTION

To achieve innovative benefit design within an organization you must expect &

overcome the 15 Killers

http://rickcartor.wordpress.com

A Method to Overcome the 15 Killers


SeekStructure& Steal



SEEK clarity

STRUCTURE the problem

STEAL effective solutions



SEEK clarity on criteria

= Set Objectives / goals

STRUCTURE the problem

STEAL effective solutions

Our values? Goals / strategy?Talent management strategy? Comp philosophy? Role of EB?



STRUCTURE the problem:Small groupIdeal (goal) – Current = Gap -Problem statement (time) -Gather data







Potential solutions

a. Generate (Brainstorm, etc.)b. STEAL effective solutions

Positive Deviance




Positive Deviance

…the observation that in any community, there are people whose uncommon but successful behaviors or strategies enable them to find better solutions to a problem than their peers, despite facing similar challenges and having no extra resources or knowledge than their peers.


POSITIVE DEVIANCE

• Best for complex non technical problems where solutions depend on behavioral / social change

• HEALTHCARE BENEFIT INNOVATIONS: - NOT exact PD application + Steps & lessons

Steps & Details• DEFINE

– The problem (causes, challenges, constraints, current practices, desired outcomes)

• DETERMINE – Find [true] PDs’

• DISCOVER– uncommon, successful behaviors– similar to behavioral interview discipline

----------------------------------------------------DECISION TO PROCEED / APPLY THIS

SOLUTION----------------------------------------------------

• DESIGN– develop plan of action, practice,

activities, involvement • EVALUATE / MONITOR

– Keep group involvement, commitment

Use group / participant approach to finding, learning

Carefully match the situation / context

Respect / tap the collective expertise in the PD groupAssume that making it work is in the details

Ask open ended Qs, probe, follow upEncourage stories, information, details, visualsUse silence, don’t end, move on or sum too fastFocus on behaviors/actions, details

Goal: learn “HOW” not “WHAT” or “WHY”




Potential solutions

a. Generate (Brainstorm, etc.)b. STEAL effective solutions

Positive Deviance:

Monitor & Compare

Implement (pilot?)

Evaluate & Select




Good sources of related content


Cartor, Rick. 2013. What I’ve Learned So Far. http://rickcartor.wordpress.comCooperrider, DL and Whitney, D. (2010) The Appreciative Inquiry HandbookGoldhill, David (2013) Catastrophic Care: How American Health Care Killed My

Father--and How We Can Fix It Heath, C. & Heath, D. (2010) Switch: How to Change Things when Change is HardHerzlinger, Regina. (2007) Who Killed Health Care?: America's $2 Trillion Medical

Problem - and the Consumer-Driven Cure National Business Coalition on Health http://www.nbch.org/National Business Group on Health, http://www.businessgrouphealth.org/ Pascale Richard; Sternin, Jerry and Sternin, Monique (2010) The Power of Positive

Deviance: How Unlikely Innovators Solve the World's Toughest Problems Potter, Wendall. (2011) Deadly SpinStarfield, Barbara, Johns Hopkins University. Miscellaneous articles and booksThaler, Richard H. & Sunstein, Cass R. (2009) Nudge: Improving Decisions About

Health, Wealth, and Happiness

http://rickcartor.wordpress.com/

http://www.nbch.org/

http://www.businessgrouphealth.org/


The GOALS of this session are: 1. understand how key players are responding to healthcare

reform so employers can find ways to survive and thrive2. enable participants to recognize and overcome common

obstacles to innovative solutions in healthcare benefit design.

NOT-a thorough review of PPACA-a debate on PPACA merits-a how to for specific mandates-a how to for being deviant



Dr. Rick Cartor, Director, ChD, LLC HR/OD Consultant @ BB&T Insurance

Louisville, KY


positive deviance: innovative responses to healthcare reform

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