Thursday, August 14, 2014

Big Data in Healthcare

Big Data in Healthcare: Unrealized Potential

An omnipresent buzzword, “big data” is currently having an enormous effect on the healthcare industry.  Providers and insurance companies are attempting to utilize big data to further understand their patients and lower costs while other companies see opportunities in helping them do so.  While challenges remain, this phenomenon is having a dramatic effect on how providers and consumers experience healthcare.

Providers
Providers are coming around to the potential in big data.  “I find this to be incredibly exciting.  The real power is to be able to use the data to make decisions,” says David Feinberg, chief executive of UCLA Health System.  Providers are utilizing big data in an attempt to decipher macro trends that can help them target their efforts and lower costs.  The goal is to move the approach to healthcare from reactive to proactive.  Providers are using big data to identify “high-risk” patients and create coordinated care plans in order to manage costs.   Providers are also focusing on lowering readmissions with Medicare readmission penalties increasing (totaling $227 million in the latest round).   In addition, providers are experimenting with new approaches to better serve these high-risk patients. Some enterprising doctors are putting personal data trackers on their patients in an attempt to collect pertinent and timely data. 

Insurance Companies
Insurance companies are using big data in an attempt to better understand their patients and nudge them toward healthier behavior.  Insurance companies such as Humana argue these efforts are mutually beneficial as patients will become healthier and insurance companies will realize lower costs.   One example of insurance companies harnessing big data to better understand patients is the building of evidence-based personalized care plans through electronic medical records.

New Opportunities
The Affordable Care Act has created opportunities and incentives for companies to harness big data in an attempt to bring down healthcare costs.  Companies such as Google see financial potential in utilizing the increasing amounts of data collected to make healthcare more proactive.  While regulatory burdens may prove challenging, companies are finding opportunities by providing PHI solutions.

Challenges        
While the potential is great, all healthcare industry parties face challenges in effectively implementing big data strategies.  As new big data healthcare apps and products are rushing to market, complaints arise that the FDA is too slow to regulate and controversy remains over what the FDA should and should not regulate.  Others retort that FDA oversight is crucial in ensuring consumer safety and confidence. Debate rages over whether the government is slowing or promoting innovation.   An additional concern is that providers and companies need time to amass sufficient data and it can be difficult analyzing the results to create a coherent strategy.  Finally, privacy concerns will continue to hinder hospitals and companies.  In order to successfully utilize big data in healthcare, companies and providers will need increasing and continuous amounts of patient information to glean details regarding their lifestyles.  Due to the sensitive nature of health information, these efforts may be stymied by privacy advocacy groups and government regulations.


Michael T. Putnam is a Senior Associate at Triage Consulting Group in San Francisco, CA. He has a B.A. in International Relations, with a minor in Business, from the University of Southern California.

Wednesday, April 9, 2014

Rising Investment in Healthcare: Opportunities and Disruptions


Rising Investment in Healthcare: Opportunities and Disruptions

The Affordable Care Act has caused a massive shake-up of the healthcare industry in a variety of ways. While mainstream press coverage has primarily focused on the political implications, the healthcare business landscape has radically changed due to new incentives and opportunities created by the reform.  The disappointing initial introduction of the ACA’s website notwithstanding, incredible progress has been made in healthcare technology.  A record $700 million was invested in digital health in the first quarter of 2014.   Below describes products and companies that are already impacting providers and consumers and those that will do so in the future.

Products that Impact Consumers
Companies have invested many dollars in developing products that target individual consumers.  Some companies have found opportunities in the ACA’s insurance mandate, such as products that assist people in signing up for health insurance.  Wearables and other wellness apps have perhaps gotten the most attention, due to large players such as Google, Samsung and Apple joining the fray.  Whether the wearable industry will be a fad or a sustainable industry is being called into question due to new research suggesting one-third of American consumers who have owned a wearable device stopped using it within six months.  However, companies will continue to invest money into ideas and products that deliver information quickly and in more innovative ways to consumers.  Younger people have shown they want to interact with their healthcare in a different and more involved way and the ACA has paved the way for new startups that will help them do so.  Examples include an app that turns health goal achievement into a game and a company that uses live, two-way video to connect fitness trainers and clients.  Studies have shown that mobile health applications could have more dramatic effects; a Mayo Clinic study found one such application reduced cardiac readmissions by 40 percent.

Products that Impact Providers
Many companies are now investing in products that could ultimately help providers as they battle to lower costs and increase healthcare outcomes.   Initially, providers focused on adopting electronic health records (EHRs) due to corresponding financial rewards (starting in 2011 and continuing through 2016) included in the ACA.  From 2012 to 2013, use of health IT more than doubled.  Providers are also being affected by companies that focus on healthcare pricing transparency.  Some of these companies, such as Castlight, have been rewarded by investors and the stock market due to optimism that they can help contain healthcare costs.  Individuals are becoming more directly exposed to the cost of healthcare via increased patient responsibility.  A report found that patient out-of-pocket costs increased by 22% from 2011 to 2012.  Patients will become more involved in their care due to increased financial responsibility and, thanks to companies like Castlight, will now have the tools to better evaluate their hospital options.  Hospitals may find themselves under increasing pressure to maintain competitive pricing rates in order to attract patients.  

Room for Opportunity
Companies are increasingly investing in the healthcare industry to create more innovative products that aim to increase the quality of care while lowering costs.  Hospitals and individuals will need to continue to engage with these products to realize their benefits, while providers in particular must be aware of their disruptive potential and adapt.

Michael T. Putnam is a Senior Associate at Triage Consulting Group in San Francisco, CA. He has a B.A. in International Relations, with a minor in Business, from the University of Southern California.

Sunday, April 6, 2014

Farming in America: The Origins and Costs of Contemporary Agricultural Policy






Farming in America: The Origins and Costs of Contemporary Agricultural Policy

In today’s debt conscious United States, where every dollar spent by the government is meticulously analyzed and oftentimes criticized, the government’s huge financial role in the agriculture industry is largely ignored in spending debates.  The recent passage of the $956 billion 2014 farm bill (formally the “Agricultural Act of 2014”) reflects this disconnect, as the overarching framework remains reminiscent of a radically different industry and time in American history. There are benefits to the continuation of this Depression-era policy, but considerable drawbacks persist. Ultimately, policymakers and budget watchers should reassess agriculture’s entitlement to government assistance.

Evolution of the American Farming Industry

Food production is radically different today than when the Agriculture Adjustment Act was first passed in 1933 as a reaction to the Great Depression and its devastating impact on the nation’s farm community.  At that time, the U.S. farm industry employed half the population, mostly on small farms. Crop prices plunged by 60 percent as farmers continued to produce more as prices fell in an attempt to maintain incomes, thus continuing the vicious circle as the increased supply only drove prices down further. Farmers began losing their farms, thus potentially imperiling the nation’s food supply.  The US intervened to guarantee crop prices and farmer incomes.  The AAA was based on farm 
price and income support programs, which have 
remained a pillar of US Agriculture policy to this day.

Attempts to Revise AAA
As innovation, technology, and continued barriers to imports caused large surpluses, and lower prices, in the 1960s, the U.S. government increased its efforts to pay farmers to not plant crops in an attempt to stabilize prices. The Food and Agriculture Act of 1965 reduced price supports and created new income supports via direct income payments to farmers who agreed to participate in acreage-reduction programs. From the 1970s to 1990s, the government mostly reaffirmed its position in agriculture with some modifications including target prices (government reimbursing farmers if crop prices fell below a certain level) and the creation of food stamps. 
By 1996, despite the highest crop prices in twenty years, farmers were receiving 21 percent of their income from the government. The Republican legislature, with Democrat President Bill Clinton’s approval, attempted to wean farmers off federal subsidies.  However, this attempt to lessen the government’s role in agriculture failed as farmers glutted the market and prices dropped significantly.  From 1996-2000, corn saw the largest five year decrease in price since 1974.[1]   
As a result, the government enacted emergency payments to farmers and continued income supports.  In 2002, the Farm Security and Rural Development Act introduced counter cyclical payments triggered when crop commodity prices fell below a certain level. 

Current Environment
Today, most Americans no longer participate in or rely on farming for their livelihoods. Farm industry workers make up slightly less than one percent of the population.  Since 1900, the number of farms in the United States has fallen sixty-three percent; the farm industry now primarily consists of a large number of massive, concentrated farms in rural areas. Ninety-three percent of farming households receive “off-farm” income (for example, income from members of the family who work in towns). Farmers receive an average of $11,922 in subsidies each year; however sixty-two percent of farmers did not collect any subsidy payments while ten percent of farmers collected seventy-five percent of all subsidies. [2] [3] Despite this new agricultural reality, government policy towards agriculture has remained largely unchanged. 

There are some compelling advantages, as well some severe disadvantages, of this continuity.

Benefits of Current Government Policy     

Defenders of contemporary agricultural policy coalesce around three major arguments: food stability, economic growth, and contribution to U.S. foreign aid.

Stable Food Supply
Proponents of government involvement argue that subsidies are the only way to guarantee a safe and secure food supply.  Crop prices are inherently volatile due to weather conditions and market movements outside their control.  Government insurance programs smooth out the peaks and valleys which allow farmers to continue planting both in tight and plentiful years.  This benefits not only farmers but the entire U.S. which perhaps takes for granted its stable food prices caused by the willingness of farmers to continue plowing their land.  If farmers are not guaranteed payment for certain crops or certain amounts of crops, farmers may take land in and out of production, causing food prices to fluctuate.  In a drastic scenario, proponents envision a Great Depression-like scenario where falling food prices and minimal government involvement cause farmers to lose their livelihood and the food supply to decrease to dangerous levels.   Only with crop insurance and other subsidies, supporters argue, will farmers be convinced to continue planting the crops on which America relies. 

Strong and Powerful Industry
Continued strong government support of the US agriculture industry has helped made it a worldwide leader, thus helping the US economy.  A strong agriculture industry that is a net exporter helps decrease the US trade deficit, a growing concern.  In 2013, the global rise of prices of soybeans, corn and wheat led to a record year of agriculture exports, exceeding $141 billion.[4]  The amount is continuing to grow as developing countries mature and demand more of these staples.   Currently sixty-five percent of US agriculture exports go to developing countries.[5]  Supporters argue that the benefits to the US economy from government involvement, including a stronger farm industry and a reduced trade deficit, far outweigh the costs.
Boosting U.S. Foreign Aid
The United States is the largest donor of food aid in the world.  Countries around the globe, from Afghanistan to Zimbabwe, depend on the U.S. to feed their populations; when a disaster occurs, the United States is often the first and among the most generous to step in. None of this would be possible without an efficient and strong agriculture system that creates more than enough food to feed Americans.  The United States has numerous programs and agencies that administer food aid worldwide.  The Food for Peace Program has directly benefited more than three billion people in 150 countries since its inception in 1954.[6]  In 2011, U.S. Department of Agriculture (USDA) food aid alone amounted to $1.9 billion. In the words of President John F. Kennedy, “Food is strength, and food is peace, and food is freedom, and food is a helping to people around the world whose good will and friendship we want.”  In addition to the positive ethical aspects of US delivering food to help feed the global community, in a world of declining US military budgets, the soft power President Kennedy references could prove to become increasingly useful.

Negatives of Current Government Policy

The above arguments make a potent case for heavy US government involvement in agriculture via subsidies and price and income supports.  Downsides persist, however, that should make policymakers rethink contemporary policy.

Undermining America’s Free Trade Efforts
The United States bills itself as a model of free trade but fiercely protects its farm industry.  U.S. trade negotiators travel the word attempting to persuade foreign countries to lower trade barriers and allow US companies to compete in their markets; foreign countries are loath to make concessions, however, while the US stubbornly maintains that its farm subsidies are off limits.  In 2002, Brazil brought the US to the WTO complaining about unfair government subsidies that U.S. cotton farmers receive.[7]  The WTO ruled in Brazil’s favor and two subsequent US appeals were overruled.[8]   Rather than retaliating by slapping increased tariffs on US cotton and other American imported goods, which would only hurt Brazil’s economy, Brazil threatened to suspend hundreds of millions of dollars worth of intellectual property protections on US companies’ software, pharmaceuticals, movies and more.  This proved a far more compelling argument to US, who then agreed to pay Brazil $147 million a year until a new farm bill was passed which would fix the issue.  Brazil and the US now disagree whether the 2014 Farm Bill adequately addresses Brazil’s concerns and the dispute remains ongoing.  Even when countries determine the pain of blocking US agricultural imports too great to stomach, they will still find ways to respond which negatively affects all parties.  While impossible to completely measure, the opportunity costs of missed trade and foreign policy costs of alienating crucial trade partners with farm subsidies is significant. 

Contributing to U.S. Debt
As “fiscal cliff” and “debt ceiling” ingrain themselves more into America’s vocabulary, every dollar spent by the US government will be scrutinized and its effectiveness judged.  Experts have estimated that the US government pays about $20 billion in cash annually to farmers and owners of farmland via direct subsidies.[9]  In 2012, Bloomberg reported that the USDA spent $14 billion insuring farmers against the loss of crop or income, almost seven times more than in fiscal 2000. [10]  With the passage of the Agriculture Act of 2014 and its increased use of crop insurance, this number will likely continue to increase.  While US voters may determine supporting US agriculture is worth paying such expenses, they should become more aware of the costs to them as taxpayers.

Fostering Dependence and Indefinite Foreign Aid
While U.S. agricultural aid has undoubtedly had a positive impact on the world, some of those involved in the industry, notably Howard G. Buffet, have detailed some of the negative consequences of an overabundance of free food aid to developing countries.  These experts argue that while necessary in emergencies and other short term situations, continuous aid perpetuates the dependencies these countries have on aid country and organizations.  As the US gives away grain and other food supplies, companies within those recipient countries lose the incentive and ability to grow.  While at times, non-US governments have no choice but to buy from foreign food companies to feed their people, always doing so undercuts native companies who find it impossible to grow and develop business models while competing with world class foreign companies.  While the US should continue to be a leader in delivering food aid to those in desperate conditions around the world, it should also revisit its approaches in order to challenge the dependencies and market-distorting consequences, as well as unending foreign aid commitments, that result from long-term food aid.

Conclusion

Are US food security, a strong export industry and foreign aid programs worth the price of missed trade opportunities, increased deficits and dependencies of developing countries?  Are we building a secure food production system or are we compensating an already well-paid industry to take more risks?  The financial strength of the farm industry and appeal of its claim to American cultural heritage have long derailed a robust debate about the economic trade-offs of American agricultural policy.  The recent farm bill partly overruled industry complaints in removing direct payments (regardless of planting), a step in the right direction. However, more needs to be done. History has shown that the recent years of high crop prices will end at some point; with increased crop insurance, the US would find itself looking at a massive cost to taxpayers if a slump occurs.  It would be better to discuss that scenario now rather than waiting.   Government support for agriculture will never and, should never, be completely eliminated, for food security reasons, in particular.  However, a more discerning eye must be turned on an industry that for years has been shielded from intense scrutiny due to its lobbying efforts and perceived place in American culture.

Michael T. Putnam is a Senior Associate at Triage Consulting Group in San Francisco, CA. He has a B.A. in International Relations, with a minor in Business, from the University of Southern California.


[1] http://farmdocdaily.illinois.edu/2014/03/arc-plc-decision-importance-of-price-path-corn.html
[2] http://www.ewg.org/agmag/2010/05/farm-income-data-debunks-subsidy-myths
[3] http://farm.ewg.org/region.php
[4] http://www.nasda.org/File.aspx?id=25749
[5] http://www.pbs.org/newshour/updates/heres-one-important-part-farm-bill-probably-havent-heard/
[6] http://foodaid.org/food-aid-programs/food-for-peace/
[7] http://www.voanews.com/content/brazil-says-us-farm-bill-violates-trade-rules-/1856057.html
[8] http://www.wto.org/english/tratop_e/dispu_e/cases_e/ds267_e.htm
[9] https://www.zambianwatchdog.com/usa-govt-pays-20-billion-to-farm-subsidies-a-year/
[10] http://www.bloomberg.com/news/2013-09-09/farmers-boost-revenue-sowing-subsidies-for-crop-insurance.html