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Vengefulseven

The Medical Billing Highway Concept (Looking for Guidance or Collaboration)

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Hi everyone,

I posted about this the other day, but never really received the answer I was looking for.  Hopefully, a concept paper with more detail of what exactly I'm envisioning can make the picture more clear.   I have a link to a Google doc below.  I'm looking for anyone who has the skill sets to help solve such a massive problem.  I'm definitely an idealist, but I also understand that the concept may need to be tweaked if my imagination has exceeded what is technologically feasible.  

https://docs.google.com/document/d/1JRAaHWa3kg7q_R0-zIkpUlilKWjI6iJfDzobHvwNsq4/edit?usp=sharing

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@Vengefulseven - Props to you in trying to solve this gigantic problem, but after reading your proposal, this project is doomed to fail (no offense).  You have overlooked many nuances of the medical industry that many people do not see.  I understand that you have worked in the finance side of the medical industry, but I would recommend that you work in the following areas to gain more perspective on how to solve the problem:  hospital, billing company, payer, an insurance company, MSO, and IPA.

Just a word of advice, commercial insurance rules are derived from Medicare.  If you want to fix the commercial problem, fix Medicare/Medicaid first, then commercial will fall in line.

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2 hours ago, IAmATroll said:

@Vengefulseven - Props to you in trying to solve this gigantic problem, but after reading your proposal, this project is doomed to fail (no offense).  You have overlooked many nuances of the medical industry that many people do not see.  I understand that you have worked in the finance side of the medical industry, but I would recommend that you work in the following areas to gain more perspective on how to solve the problem:  hospital, billing company, payer, an insurance company, MSO, and IPA.

Just a word of advice, commercial insurance rules are derived from Medicare.  If you want to fix the commercial problem, fix Medicare/Medicaid first, then commercial will fall in line.

Actually,

I appreciate honest opinions.  I spent some time working with CMS, albiet as a contractor.  I don't personally think going through them first is the correct approach.  They are slow to adapt to change.  

I did not mention it in the paper because I wrote that over a year ago and put the idea to rest for a while to focus on other projects. I would actually approach the clinical trial industry first.  I'm more likely find interested parties by working through the pain points between hospitals and research sponsors (pharma). 

Hospitals (sites) tend to utilize a CTMS (clinic trial management systems) while sponsors (pharma) utilize EDCs (electronic data capture systems).  The two do not communicate.  If there was a way to make these two systems communicate, we could create a system where data can be entered, monitored, and paid for in a matter of days rather than the current standard which is quarterly or at best monthly.  

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3 hours ago, aye-epp said:

Thanks for sharing your idea

What specifically are you looking for?  (Co-)founders? Programmers? PMs? Capital? 

No capital or PMs needed at this phase.  Right now, a programmer would be best.  Someone who can tell me if my idealism is beyond what is currently possible.  

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Posted (edited)
On 5/7/2019 at 10:54 PM, Vengefulseven said:

No capital or PMs needed at this phase.  Right now, a programmer would be best.  Someone who can tell me if my idealism is beyond what is currently possible.  

Our CTO has a history working in medical companies, as do our attorneys. In one meeting, they all started laughing because the financial situation/service we were discussing, if done wrong, could cause material harm to the users. 

Now they weren't laughing at causing harm, they were laughing because both the legal and tech requirements were essentially nothing... as compared to medical projects they had worked on.

That said, I'd suggest you look towards Enigma.io I'm saying that because they have ZKP, and the ability to make markets on (health) data, between two parties where one needs to share private data (healthcare users) with another party (insurance inc) who has the ability to process the data creating Information... without the raw data being disclosed to the party processing the data. 

If I remember correctly, it was the HIPAA laws that called for more effort than investment laws.

Edited by KarmaCoverage

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Posted (edited)
On 3/31/2020 at 7:39 AM, KarmaCoverage said:

That said, I'd suggest you look towards Enigma.io I'm saying that because they have ZKP, and the ability to make markets on (health) data, between two parties where one needs to share private data (healthcare users) with another party (insurance inc) who has the ability to process the data creating Information... without the raw data being disclosed to the party processing the data.

I wish that technology luck.  As it is, at least in the US, we are headed toward a "care decisions made by an algorithm at the central office" system, with EHR's accessible not only to insurers and "analytics" companies, but, through the "public health" and "law enforcement" partnerships, to the government.  A national ID # for each citizen already exists in a database within HHS.  This latest virus "crisis" was used to push through laws which will mandate all prescription history (not just controlled substances) goes into a database (accessible by your doctor, researchers, administrative agencies, the cop pulling you over for speeding, the background check company your employer uses, etc).  It's really bad.

But, hey, it *might* lead to some sort of research breakthrough!  Or it might save lives!  (Or - and my money is on this - it might just invade privacy and exponentiate corruption.)

All of that to say, zero-knowledge-proofs are great - but they defeat the snooping bastards who want to be able to view that data (you know, to "help" us), so, that's a hard sell...

IBM's Watson was supposed to have cured... something... by now, right?  Turns out that Big Data and Big Analytics and "AI" are useless when all of the data is inhomogenous - which is why we're seeing these pushes to turn doctors into "algorithm extensions" and "data entry clerks" and researchers studying and trying to standardize the practicing of medicine (no matter how many people they **** over and misdiagnose, mistreat, or worse in the process) so that they can force some kind of "benefit" out of all the snooping.

May they all go blind.

 

 

 

Edited by NightJanitor

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I have given a lot of thought to this process, and I have been to conferences that discuss the future plans for digital healthcare.

I do think there are a lot of opportunities here, but I also believe this is an entire cluster of industries whose profit models rely on asymmetry of information and inefficiency.

The flow of payments in healthcare goes through a pretty confounding slope of care that is designed to grow administrative costs and make quality of care the lowest priority for most healthcare institutions.

This is not to say doctors do not want to provide the best care they are qualified to give. Most of them absolutely do. But there are many layers to this cake.

At the moment, you have three distinct entities working very hard to remove the other entity from the relationship as an unnecessary middleman.

Big Data - big data has behavioral data by the metric ton, what they lack is provider network that can provide the care and an efficient infrastructure that will allow them to control all of the verticals of the process. And yeah, they are courting big pharma in big ways.

Hospital Networks - hospitals have a lot of provider insight and boots on the ground influence on patient culture, but they acknowledge that 40%+ of a patient's well-being depends on their behaviors - not clinical time. It's the wellness, IoT, medication management pipeline they would like to develop - they have the frontline access but lack control over the cost structure and the logistics higher up the chain. They'd like to go at-risk if they could understand and control their cost per patient, but getting the cost and risk management right is challenging.

Insurance Companies - insurance companies have decades of data on patient health, and the let it out in claims reports months behind real-time activity. You want to understand why progress is slow in medical advancement and the development of effective treatments? It is very hard to make broad evaluations of health conditions when your cost data and claims data are so laggy. Insurance companies have segmented and stratified networks, they know how much your body is worth and they know how much your body costs to maintain. But they don't talk to you (except in cheesy commercials) and would like very much to accept your premiums and never have to pay you a dime. They are financial product managers, not health and wellness experts.

I believe the big partnership alliance is going to be between big data and provider-direct care. If Amazon introduces Prime Health, and they use the data for their Treasure Trucks to understand what price points and delivery locations will serve as the best means for providing mobile health and wellness facilities, and they develop a solid package that includes disruptive IoT technology and personalized prescription dosage deliver (which they have) - smart medicine cabinets that can check-in and keep count of your medications, keep appointments for telehealth script management - even provide authentic proof that you have held and ingested the right medication. Blood pressure monitors, heart rate monitors, consistent glucose monitor sensors, smart scales - If they can do this, they can also provide behavioral cues and advice to manage patient activity levels, sedentary levels, food choices, drink choices, they can provide discount incentives for music, travel audio devices, audiobooks, that work in concert with provider recommendations - and wellness tracking.

All of it, big data can handle all of it. No more weird points that your insurance companies begrudging awards you in your wellness plan - where half the time you get Amazon gift cards anyway because you already have a fitbit, etc. Insurance is late to the party on behavioral management - If you act wrong, they'd rather dump you than help you. You must have missed that commercial though.

But payment rails - if you want to make a difference in payment rails, you would need a way to reliably pay people in XRP to fulfill wellness recommendations. Would you participate in a 5k if doing so would earn you 1000 XRP?

Because of the industry shift from volume-based care payments to value-based care, all of the standard tools which originally empowered medical facilities and providers and took power and knowledge away from the patient (because they'd keep coming in if you discouraged self-care, etc.) are now having to revamp and give the patient tons of agency, tons of information, tons of incentive to stay healthy - within the recommended HEDIS guidelines, for example - and only see providers in order to fill gaps in care that make them fall short of the recommendations. To make money, you need the best health outcomes with the least visits.

Facilities will now want to see patients less, not more. They want the patients to be empowered to do as much self-care at home as they can, because from here on out they will make money when patients see them less and stay healthier. Home health is big. Telemedicine is big.

I hope you understand - the opportunity to develop solid flows of income are going to center around the patient - very soon - and so tying micropayments to IoT in healthcare is going to be the biggest disruption of all - and here it is big data and their adoption of cutting edge tech that will win out over the legacy claims-based risk management and stratification data - once Amazon or Google or Apple have enough realtime data streaming live from all of their subscription devices, they will be able to direct your personal health and wellness trajectory and goals as effectively as they can navigate you to the nearest gas station...

Yeah, shudder.

So insurance is prettttty desperate right now to make friends with retailers - ever wonder why the best they can do is offer you gift cards? So payment rails? Meh. If hospitals could do it, if they had full transparency over their logistic verticals for supplies and medications thanks to big data retail and could also benefit from real-time analysis and commercial incentives built around behavioral trending data of patients by fusing IoT and purchasing/browsing history - well, their own risk management and stratification of patients for treatment panels, comorbidity panels, research trials, etc. would be great - they would go full at-risk and manage their own concierge medical care platform.

And if you don't think Amazon - at the very least - isn't already doing that. Well, if you work for Amazon and you know they aren't already doing that - please PM me. :-D

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The company I work for has gone about conforming to best practices  in a highly regulated area involving event,  payment and tracking by successively obtaining clearances from the concerned state and federal regulatory agencies.  After three  years of working with lawyers and  regulators in several  agencies, we submitted a bid just this last week. Our approach begins with use case, law and then you apply the tech. In determining the law, you allow the agency to pick apart your design and as a function of law practice with close tech consultation, adjust the protocol to their input. recognize that there are very oftentimes multiple jurisdictions and there are layers of  concerned agencies which should be included as stakeholders  Not until you have the regulatory approach down solid, do you finally apply the tech.  (There is a well-known book on what not to do in  kicking off these startups. " Lean Startup.")  You do best by combining subject matter experts, specialized lawyers, data architects and coders.  You need either a very good idea to attract these skill sets or a very deep pocket to pay for the expertise.  The mistake of proceeding with the  tech design first does not seem to always work.  In fact more and more it has demonstrated a shortsightedness that leads to insolvent disaster.    Witness Libra which is foundering even with the Swiss Finma.  "Moving fast and breaking things" the mantra of the first innovators  has not been successful with the current more tech savvy and tech hostile regulatory environment. This lawless and reactionary approach   is a good way to go broke yourself in the best scenario and if you look at the legal challenges faced by Telegram and Ripple, it is really stupid and unfair to investors.

 

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Yeah... the technologists who complain that health data is inhomogenous ultimately wind up becoming "dispositionalists" and blame patients for being inhomogenous and all acting and being different and eating different stuff and doing different things and making the precious techno-gizmos not work right!  Darned humans and their darn free will!

Can't imagine why those models encounter resistance.

(I do like concierge and the direct primary care model.)

(Of course, those don't scale up into a centralized, totalitarian, control what you eat/drink/read and then monitor what you think/say/shit - so, that might be part of the appeal.)

:)

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https://www.statnews.com/2020/04/24/coronavirus-hospitals-use-ai-to-predict-patient-decline-before-knowing-it-works/

"Beep, boop, beep.  Your Grandma experienced an unexpected anomaly and expired.  Please insert your other Grandma."

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