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Positive Deviance: Innovative Responses to Healthcare Reform. Dr. Rick Cartor, Director, ChD, LLC HR/OD Consultant @ BB&T Insurance Louisville, KY. Positive Deviance: Innovative Responses to Healthcare Reform. Outline and Goals The HCR context

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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


Positive deviance innovative responses to healthcare reform1
Positive Deviance: Innovative Responses to Healthcare Reform

  • Outline and Goals

  • The HCR context

  • Key Player Responses: Payers, Providers, Users

  • Users: Obstacles to Innovation

    • Overcoming the Obstacles

http://rickcartor.wordpress.com


Positive Deviance: Innovative Responses to Healthcare Reform

  • The GOALS of this session are:

  • understand how key players are responding to healthcare reform so employers can find ways to survive and thrive

  • enable participants to recognize and overcome common obstacles to innovative solutions in healthcare benefit design.

-a thorough review of PPACA

-a debate on PPACA merits

-a how to for specific mandates

-a how to for being deviant

NOT

3

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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 challengesand 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

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-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”

“Necessity is

the mother

of invention.”

There are many in this

similar situation

Resist the tendency to act alone

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5


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

But the key players remain the same – and are each adapting


$-Payer

+ Provider

User / group

7


$-Payer

  • Diversify:

  • New products / M&A

  • stop loss; level premium

  • ASO/TPA

  • Data sales

  • Medical management

  • IT services (exchanges)

  • Wellness programs

  • Care & Clinics

  • Telemed / kiosks

  • DM

  • Cost:

  • 1. Relationships

  • a. Provider focused:

    • Collab w providers

    • Shift risk: Pay for Perf

      • Outcome based

      • ACOs / Med Homes

    • Narrow Networks

  • b. Member focused:

    • Modify behaviors

      • Preventive

      • Transparency

      • Rx tiers

  • 2. Admin costs

    • Technology: Auto enroll;

      • adjudication, portals

    • Simplify for exchanges

    • Outsource / offshore

  • Retail:

  • Indiv / small group

  • 90+% covered

  • 50% fewer via broker

  • ¾ direct to consumer

  • Bare minimum / EB

  • States’ M&M


Younger, more male & white

Less obese, more smokers & drinkers


  • Related Diversific

  • Wellness

  • Biomets

  • Lab work

  • Targeted DM

  • TPA

  • HCIT

  • EAPs

Quality, Cost Outcomes

Direct Employer contact

Population management

ACO / PCMH/ PCP nets

On site clinics

Managed Care / Integrated care

Physician practices

Networks, narrow

Physician extenders / PA

New entrants:

WalMart, mini-clinics,

Primary Care clinics,

Wellness & biometrics,

MD2U, DM,

Labs (franchises!)

+ Provider

11


  • FTE/PTE: hours

  • INCREASE PREVENTION

  • Encouraging Essential benefits

  • Wellness

  • Premium incentives for employees

  • Carrot / stick

  • Rewards for P’ then results

  • drawings vs. rewards

  • contests

  • Onsite coaches (w + DM)

  • Chronic costs/ non-adherence

  • On site near site / shared solo clinics

  • Primary care externeders

  • Reduce ICC & ER

  • Telemedicine and Kiosks

  • Medical homes

  • Policies / Reward redesigns

  • Hiring practices

    • food on site, fit bits, clubs,

    • On site fitness

    • Rewards for PCP

  • DEPENDENT AUDITS

  • PURCHASING COALITIONS

  • TRANSPARENCY TOOLS

ATTN TO PROVIDERS AND PAYERS

PROVIDER CONCESSIONS

Premium rebates

Premium discounts (W, PCC, etc)

Related discounts (LTD for PCC)

TPA/ASO

Self-funding

Lower stop loss (spec/agg)

Level premium

PARTNERSHIPS

Consultants v broker

Data demands analytics

Managed care / Population

management / ACO BC3

Inpatient Care:

Narrow networks, tiers, steer

Pass through Rx; tiers, incentives

mail, generics, partner, unbundle

COMMUNITY RATING:

associations, captives;

private exchanges

<49

50-100

101+

User / group

12


  • 15 MISTAKENBeliefs

  • that KILL innovative healthcare benefit design within

  • Beliefs and Assumptions about:

    • Healthcare in general

    • How to find a solution

    • How to implement a solution

User groups

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MISTAKEN

BELIEFS & ASSUMPTIONS ABOUT…

(A) HEALTH CARE IN GENERAL

U.S. healthcare is unfixable

There are no good solutions

Healthcare decisions are separate from…

SSDD 

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MISTAKEN

BELIEFS & ASSUMPTIONS ABOUT…

(B) HOW TO FIND A SOLUTION

  • 5. In bounds & out of bounds

  • 6. Criteria: unclear, unstated, assumed...

  • We have to think in 12 month cycles

  • We have to settle for insufficient data

  • We have no partners - but many adversaries

  • “Innovative” = high risk

    • Uncommon, Fast Follow, Early Adopter,

  • 11. Things will settle down soon…one answer

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MISTAKEN

BELIEFS & ASSUMPTIONS ABOUT…

(C) IMPLEMENTING THE 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

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To achieve innovative benefit design within an organization you must expect overcome the 15 killers
To achieve innovative benefit design within an organization you must expect & overcome the 15 Killers

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A method to overcome the 15 killers
A Method to Overcome the 15 Killers you must expect & overcome the 15 Killers

Seek

Structure

& Steal

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SEEK clarity you must expect & overcome the 15 Killers

STRUCTURE the problem

Seek

Structure

& Steal

STEAL effective solutions

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Our values? Goals / strategy? you must expect & overcome the 15 Killers

Talent management strategy?

Comp philosophy? Role of EB?

SEEK clarity on criteria

= Set Objectives / goals

STRUCTURE the problem

Seek

Structure

& Steal

STEAL effective solutions

http://rickcartor.wordpress.com


Our values? Goals / strategy? you must expect & overcome the 15 Killers

Talent management strategy?

Comp philosophy? Role of EB?

SEEK clarity on criteria

= Set Objectives / goals

STRUCTURE the problem:

Small group

Ideal (goal) – Current = Gap

-Problem statement (time)

-Gather data

Seek

Structure

& Steal

http://rickcartor.wordpress.com


Our values? Goals / strategy? you must expect & overcome the 15 Killers

Talent management strategy?

Comp philosophy? Role of EB?

SEEK clarity on criteria

= Set Objectives / goals

  • STRUCTURE the problem:

  • Small group

  • Ideal (goal) – Current = Gap

  • -Problem statement (time)

  • -Gather data

  • Potential solutions

    • Generate

    • (Brainstorm, etc.)

Seek

Structure

& Steal

b. STEAL effective solutions

Positive Deviance

http://rickcartor.wordpress.com


Positive deviance1
Positive Deviance you must expect & overcome the 15 Killers

…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.

http://rickcartor.wordpress.com


  • POSITIVE DEVIANCE you must expect & overcome the 15 Killers

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

  • HEALTHCARE BENEFIT INNOVATIONS:

    • - NOT exact PD application

    • + Steps & lessons


Steps details
Steps & Details you must expect & overcome the 15 Killers

Use group / participant approach to finding, learning

Carefully match the situation / context

Respect / tap the collective expertise in the PD group

Assume that making it work is in the details

Ask open ended Qs, probe, follow up

Encourage stories, information, details, visuals

Use silence, don’t end, move on or sum too fast

Focus on behaviors/actions, details

Goal: learn “HOW” not “WHAT” or “WHY”

  • 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


Steps details1
Steps & Details you must expect & overcome the 15 Killers

Use group / participant approach to finding, learning

Carefully match the situation / context

Respect / tap the collective expertise in the PD group

Assume that making it work is in the details

Ask open ended Qs, probe, follow up

Encourage stories, information, details, visuals

Use silence, don’t end, move on or sum too fast

Focus on behaviors/actions, details

Goal: learn “HOW” not “WHAT” or “WHY”

  • 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


Steps details2
Steps & Details you must expect & overcome the 15 Killers

Use group / participant approach to finding, learning

Carefully match the situation / context

Respect / tap the collective expertise in the PD group

Assume that making it work is in the details

Ask open ended Qs, probe, follow up

Encourage stories, information, details, visuals

Use silence, don’t end, move on or sum too fast

Focus on behaviors/actions, details

Goal: learn “HOW” not “WHAT” or “WHY”

  • 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


Steps details3
Steps & Details you must expect & overcome the 15 Killers

Use group / participant approach to finding, learning

Carefully match the situation / context

Respect / tap the collective expertise in the PD group

Assume that making it work is in the details

Ask open ended Qs, probe, follow up

Encourage stories, information, details, visuals

Use silence, don’t end, move on or sum too fast

Focus on behaviors/actions, details

Goal: learn “HOW” not “WHAT” or “WHY”

  • 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


Our values? Goals / strategy? you must expect & overcome the 15 Killers

Talent management strategy?

Comp philosophy? Role of EB?

SEEK clarity on criteria

= Set Objectives / goals

Monitor & Compare

Implement (pilot?)

Evaluate & Select

  • STRUCTURE the problem:

  • Small group

  • Ideal (goal) – Current = Gap

  • -Problem statement (time)

  • -Gather data

  • Potential solutions

    • Generate

    • (Brainstorm, etc.)

Seek

Structure

& Steal

b. STEAL effective solutions

Positive Deviance:

http://rickcartor.wordpress.com


Good sources of related content
Good sources of related content you must expect & overcome the 15 Killers

Cartor, Rick. 2013. What I’ve Learned So Far. http://rickcartor.wordpress.com

Cooperrider, DL and Whitney, D. (2010) The Appreciative Inquiry Handbook

Goldhill, 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 Hard

Herzlinger, 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 Spin

Starfield, Barbara, Johns Hopkins University. Miscellaneous articles and books

Thaler, Richard H. & Sunstein, Cass R. (2009) Nudge: Improving Decisions About Health, Wealth, and Happiness

http://rickcartor.wordpress.com

30


Positive Deviance: Innovative Responses to Healthcare Reform you must expect & overcome the 15 Killers

  • The GOALS of this session are:

  • understand how key players are responding to healthcare reform so employers can find ways to survive and thrive

  • enable participants to recognize and overcome common obstacles to innovative solutions in healthcare benefit design.

-a thorough review of PPACA

-a debate on PPACA merits

-a how to for specific mandates

-a how to for being deviant

NOT

31

http://rickcartor.wordpress.com


Positive deviance innovative responses to healthcare reform2

Positive Deviance: Innovative Responses to Healthcare Reform you must expect & overcome the 15 Killers

Dr. Rick Cartor, Director, ChD, LLC

HR/OD Consultant @ BB&T Insurance

Louisville, KY

http://rickcartor.wordpress.com


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