Surplus of Blame, Shortage of Trust: Healthcare, Heal Thyself!


In 2012, following the HIMSS12 conference, I wrote about the importance of trust in healthcare exchange markets. Here’s an excerpt from my blog article 3 years ago:

The importance of building and maintaining trust among entities that are collaborating or exchanging goods & services is paramount. Without trust, markets where imperfect or asymmetrical information exists won’t operate efficiently. Whether we like it or not, “imperfect” and “asymmetrical” define the current mechanisms used to exchange personal health information.

So, how far have we come in three years? This guest post by Frank Ingari, President & CEO of Navinet, Inc., indicates that we still have a long way to go to develop adequate trust between payers & providers in order to achieve the level of risk-sharing and collaboration needed for new models of healthcare delivery.


Surplus of Blame, Shortage of Trust: Healthcare, Heal Thyself!

After putting in their 10,000 steps a day at HIMSS15, anyone can tell you how much blame there is to go around in the complex dysfunction of U.S. healthcare. Rapturous vendor claims aside, how do we get to the interoperable learning system described in The Office of the National Coordinator of Healthcare Information Technology’s Interoperability Roadmap?

In my blog post on the Roadmap (Will Today’s Payer Have the Role they Want Tomorrow?), I argued that we must include payers in the clinical connectivity movement to have a chance.  My friend John Moore at Chilmark Research responded with an astute critique, “The relationship(s) between payers and providers is typically not one built on a whole lot of trust. I have not seen vast and growing evidence that this is occurring—yet.”

Of course John is correct—payer-provider antagonism is deeply rooted. But imagining that we can deliver reform without addressing pervasive industry distrust is an illusion.

The truth is, trust is in short supply across the healthcare ecosystem. Doctors don’t trust lawyers or even the regulators whose regulations the lawyers enforce. Specialists often don’t trust their hospital employers to be transparent on financial productivity. EMR vendors don’t trust their competitors.  Clinicians don’t trust big data systems to provide pristine “evidence-based guidance,” while big data vendors don’t trust clinicians to tell the whole truth in the clinical record. Consumers don’t trust the healthcare “research” flooding the Internet—but they’re not too sure about the healthcare establishment either.

So how do we grow trust in healthcare? It may be that the payer-provider relationship, strange as it seems, is the best place to build a new foundation.

One scholar who has devoted much of his career to the study of societal trust is Professor Roy Lewicki, a pioneer in conflict management. He points out that trust and distrust are not true opposites: “contrary to traditional, normative views that trust is good and distrust is bad… both trust and distrust have a valid role in managing complex relationships… trust is valuable insofar as it is appropriate to the context, and a healthy amount of distrust can protect against the risk of exploitation” (Lewicki & Wiethoff, Trust, Trust Development and Trust Repair, 2000).

Lewicki’s insights support the idea that the payer-provider relationship, while historically difficult, may offer the indispensable ingredients to grow trust. Given the centrality of the payer-provider relationship to the core concept of reform (increase quality while reducing cost), this could be key to our national success.


Lewicki suggests the best way for organizations to increase trust is to use a contractual framework to demonstrate competence, consistency, predictability, empathy, and sharing of control—repeatedly, and over time. The VBR contracts proliferating between payers and providers, underlying new risk-sharing agreements, present an excellent platform for the development of mutual trust along these dimensions. Successful VBR contracts require competent performance by payer and provider, detail the sharing of control in key areas such as Medical Management, and specify the metrics and methods by which performance will be judged. The sheer number of such contracts across multiple payers and insurance products provides health systems with unparalleled opportunity to evaluate the trustworthiness of each payer as partner across multiple contract cycles. 

Lewicki goes on to suggest that it is equally important to decrease distrust –which certainly rings true in healthcare. Once again, he focuses on the central role of formal contract agreements to enable clear specification of each party’s obligations. The contract can then specify how each party’s actions can be monitored and verified, under the protection of legal recourse and supported by the existence of third party arbitrators.   

Compared with the payer-provider relationship, no other “axis of distrust” in healthcare offers such rich, powerful, or frequent contract mechanisms that can establish the repeated demonstration of trustworthiness. What’s more, the government’s growing role as the ultimate payer means that critically important standards of behavior and objective third-party regulation are increasingly transparent and available.

We at NaviNet are seeing the trust-building process play out at an accelerated rate around the country. It may be more exciting to suggest that providers are suddenly going to become payers and put the dreaded insurer out of business, but it may be more accurate to focus on the mainstream of health systems who are experimenting carefully in sequential product-specific partnerships with selected payers to explore roles, responsibilities, risks and rewards in new collaborative contracts.  This will be at least as true for the health system “payviders” who are trying to become insurers themselves, typically in close cooperation with a payer-based “value-based TPA” partner, as they develop internal payer functions such as Utilization Management for the first time.

The ONC and academic reformers could miss a golden opportunity by ignoring this trend. By the time clinical interoperability could possibly be accomplished by “provider-only” means, healthcare industry structure will have been changed utterly by virtue of the innovations spawned by cooperation between payers and providers in shared risk for Medicare Advantage, Managed Medicaid, Exchanges, and commercial ACOs.  In Darwinian fashion, the healthcare entities who thrive in reform will have learned to build trust between payer and provider functions by proving to each other that they are competent, predictable, and trustworthy by means of repeated cycles of shared-risk success in VBR contracts.



Frank Ingari is President and Chief Executive Officer of NaviNet, Inc., America’s leading healthcare collaboration network. NaviNet helps payers and providers boost care quality, lower costs, and improve population health management with NaviNet Open, its payer-provider collaboration platform. @FrankIngari


Meet Your Social Media Ambassador to HIMSS15 Conference

The annual HIMSS Conference begins next month in Chicago (April 12-16). This year, I am very pleased to announce that I was named one of the HIMSS Social Media Ambassadors for the event. The #SoME ambassadors group includes many influential, super-knowledgeable, and prolific information-curators and contributors to a wide range of publications. I know most of these people from online conversations and in many cases met them at the first HIMSS conference I attended in 2010. Needless to say, I am thrilled to be included in this group!

Follow this elite group on Twitter and you’ll be well-informed about health IT standards & policy, behavioral health, advances in EHR technology, healthcare analytics/big data, new clinical decision support services, healthcare economics and more. The group includes:        

  • Brian Ahier @ahier
  • Mandi Bishop @MandiBPro
  • Wen Dombrowski, MD @HealthcareWen
  • Susan Hull @SusanCHull
  • Gregg Masters @2healthguru
  • Janice McCallum @janicemccallum
  • Jane Sarasohn-Kahn @healthythinker
  • Shahid Shah @shahidNShah
  • Linda Stotsky @EMRAnswers
  • Michelle Troseth @CPMRCmichelle
  • Charles Webster @wareFLO

[To follow this group, subscribe to Twitter list:]

Healthcare IT News is publishing a profile of each of the SoMe ambassadors to provide more insight into the areas of specialization of each member of the group. The profiles go beyond our geeky health IT and policy backgrounds to include some lesser-known aspects of our lives. My profile was published today and I have to congratulate the writer, Scott Thaler, on incorporating so many aspects of my career in designing & marketing digital information products and overall interest in the intersection of health IT and health content. Read more to learn of some other interests of mine:

If you will be attending HIMSS15, come by the #IHeartHIT Meetup to meet me and the other SoMe ambassadors on Monday, April 13, at 3:30pm. Register here.

Whether you are attending or not, be sure to follow the #HIMSS15 hashtag on social media. Since that list may get overwhelming during the conference, I want to reinforce my recommendation to follow the #SoMe list, which is guaranteed to serve up carefully curated selections from the sessions, exhibit hall, press briefings, and social events.

I look forward to seeing many colleagues at HIMSS15. Please contact me if you would like to set up a briefing.



Springer Science+Business Merges with Holtzbrinck’s Macmillan Science Group

One could get dizzy trying to trace the M&A history of Springer Science+Business. I recall analyzing their likely future back when they were owned by two private equity companies, Cinven and Candover in the mid-2000s. Cinven & Candover had formed Springer Science + Business by merging Kluwer Academic Publishing with Springer in 2004. In late 2009, Cinven & Candover  sold Springer Science + Business to EQT, a Swedish private equity firm, for 2.3 B EUR (note, Springer held 2.2 B EUR of debt at the time).

In 2013, EQT sold Springer to BC Partners for 3.3 B EUR.

Today, it was announced that BC Partners will merge Springer with Holtzbrinck Publishing Group’s Macmillan Science Group (well, almost all of MSG). Holtzbrinck becomes majority investor with a 53% stake; BCP retains minority ownership. Derk Haank, the CEO of Springer, will become CEO of the combined company. Annette Thomas, current CEO of Macmillan, will serve as Chief Scientific Officer.

The combined entity will have 13,000 employees and annual sales of 1.5 B EUR ($1.7 B US).

The rationale for the merger centered on the need for market share in the scholarly publishing segment. Derk Haank is quoted as saying, “Together, we will be able to offer authors and contributors more publishing opportunities and institutional libraries and individual buyers will have more choice. The expected economies of scale will allow for additional investments in new product development.” 

Scale and market share are becoming increasingly important as large publishers, including Elsevier, Wolters Kluwer, and Wiley, along with Springer, are competing to acquire titles from scholarly societies and other small publishers. Having control over the high quality scientific and medical journal content allows the big publishers to reinforce the value of bundled access to their collective publications (as well as subsets of their publications). But, perhaps more important, by accumulating rights to a significant share of the journals that serve as the arbiters of quality research— and by association, quality scientific and medical evidence—these leading scientific, technical and medical (STM) publishers will remain essential to any analytics engine that aims to mine the universe of important research results.

In brief, scale affords digital information businesses far more options in their choice of business models than would be available to a small publisher. Springer Science + Business now has Nature and its portfolio of journals in its camp. Together, they should be able to better compete in a segment that will continue to consolidate.


Should We Expect Healthcare Providers to Plot Their Own Demise?

The Triple Aim of improving quality, improving patient care and reducing costs is a noble mission, but can we expect the current vendors of medical services to take the lead in reducing costs?

There is so much to debate in healthcare regarding where to focus reform efforts. Many will look at the high costs of caring for chronically ill patients and conclude that that the segment that accounts for the greatest share of expenditures must surely be the target for cost savings and disruption.  It’s difficult to argue against the need to continually improve how we care for the acutely and chronically ill. However, to use one analogy, we can’t continue to get better at putting out fires once they are in full burn without equal or greater efforts devoted to preventing fires. For the population as a whole, the benefits of prevention far outweigh the benefits of incremental improvements in managing chaos.

Given that hospitals and physician practices exist to perform medical interventions, how can we expect these organizations to lead the efforts in reducing demand for their services by promoting wellness and patient education programs?  We can’t. The same logic applies to patient engagement. How can we expect provider organizations to lead efforts that ultimately will reduce the demand for medical services? We can’t. Instead, we have patient engagement programs that predominantly target medication adherence.

Granted, there are attempts at creating patient-centered medical homes and accountable care organizations (ACOs) that have incentives to better coordinate care and attempt to reduce duplication of tests, overtreatment and medical errors, all things that should help reduce overall costs. But, it would take some pretty massive incentives to ask physician practices to become public health promotion centers. In fact, the pendulum is moving away from primary care physicians’ offering even basic preventive health services. One data point to support my statement: vaccinations are moving from primary care facilities to pharmacies. One anecdote: my mother’s primary care physician effectively refused to give her a shingles vaccine on two occasions, saying she’d be better off getting it at CVS. My mother interpreted the doctor’s comment and attitude to mean that the vaccine isn’t medically important, even though the doctor more likely was trying to save my mother some money (CVS charges less than $100;  the doctor’s administrative staff could only say that depending on her insurance, the cost to her could be as high as $300).

So, if we want to make a serious dent in the level of health care expenditures in the US, we’re going to have to bolster our public health efforts and educate and engage the greater population on how to adopt behaviors that help maintain health and avoid disease. Harvard School of Public Health received a gift of $350 million this week. That’s an encouraging sign. To quote the benefactor, Hong Kong billionaire Gerald Chan, “While medical doctors give health benefits to individual patients, public health is a field that helps to give benefit to the whole population”. [1]

While we still need better one-on-one communication between physicians and patients, we can’t expect a meaningful reduction in healthcare expenditures until we reduce the demand for medical services. And, we shouldn’t expect the providers of those services to lead the efforts to reduce demand.


[1] Source: See also:


Big Data in Healthcare and Life Sciences Reports

Three new reports on the future of Big Data in healthcare, life sciences, and urban planning (Connected Cities) are available from the Massachusetts Technology Leadership Council (MassTLC). 

I am pleased to have worked with MassTLC to produce the healthcare and life sciences reports. The reports resulted from a Delphi process that included one-on-one interviews with leading thinkers and practitioners in each field followed by an onsite roundtable meeting. The insights from the academics, researchers, industry leaders, investors, and policymakers are eye-opening and offer a balanced view on the challenges and opportunities involved in applying big data methods and tools to life sciences research and healthcare delivery. 

The reports are available for free download from the MassTLC site

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