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Q&A with Freelancers Union's Sara Horowitz on Modernizing Health Insurance

Mar 13, 2012, 5:22 AM, Posted by Pioneer Blog Team

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The Centers for Medicare & Medicaid Services last month awarded $340 million in low-interest and no-interest federal loans to three organizations sponsored by Freelancers Union, a Pioneer Portfolio grantee, to create three of the first seven Consumer Operated and Oriented Plans (CO-OPs) in New York, New Jersey and Oregon. Created by the Affordable Care Act, CO-OPs are consumer-governed health plans that use profits to lower costs for consumers, improve quality of health care, and increase enrollment or benefits based on members’ needs.

We caught up with Sara Horowitz, the founder and executive director of Freelancers Union, to gain some insight on lessons she’s learned, what it means to be truly innovative, and how to put the “health” back in health insurance. The nonprofit Freelancers Union, with 171,000 members nationwide, advocates on behalf of the 42 million independent workers in the U.S. The organization provides health insurance to over 23,000 New York freelancers and their families through its social-purpose Freelancers Insurance Company.

What gave you the idea for Freelancers Union?

I wanted to figure out the next form of unionism, because people had begun working in a completely new way. Thirty percent of the workforce now earns its living as freelancers, contractors and temps.

When I began speaking with freelancers and independent workers in the mid-90s, their biggest concern was health insurance. I came into the field with no health policy background and didn’t carry any baggage. I approached the problem of changing the health care system by trying to help working people get the health insurance they need. Focusing on our members has been my North Star when deciding which strategies could work and which won’t.

When did you decide to start your own insurance company?

What we really wanted was to merge the ideas of Kaiser Permanente with union benefit funds, bringing in the best ideas out there. We recognized that you can do the most if you’re responsible for the money, and that we couldn’t accomplish our goals without creating an insurance company.

What did you learn from talking to your members about what they want from health benefits?

The biggest lesson, which we haven’t solved yet but have made strides toward, is that our members want to get more value in what they’re spending on their health and well-being, and they should. Americans pay out-of-pocket for extra efforts they make for their health, whether that means going to the gym, taking a yoga class, or purchasing healthy foods. Our health benefits should integrate efforts that keep people healthy, not only physically, but mentally, emotionally and socially. In places like northern Italy, you don’t have to be rich to eat well. We need that kind of culture change, and I like to think we can help.

What did you learn from starting your own insurance company?

I learned that you have to know what you’re trying to achieve and understand that there are risks, even if you are unsure what the risks are. You have to build a great team that can help search for what you don’t know. You need a board that has wisdom and experience in all aspects of the field. You have to always strive to do the right thing. In the short-term, you’re making changes that are central to peoples’ lives. Sometimes, this will make them very anxious and even mad at you. You have to reaffirm that there’s no alternative and stay on course to make the situation better. If you continue to communicate and build relationships with your members, their trust and support will come back.

That’s part of what I love about the Pioneer Portfolio and the zeitgeist of social entrepreneurship. When you’re working on complex issues, change and success take time. In current politics, government officials don’t have the longevity to do that right now because we’re not giving them enough space. So, the nonprofit sector has to step in and have the patience to pioneer and experiment.

What spurred you to pursue the CO-OP?

As you can imagine, trying to plan strategically during the past year has been challenging. As we looked at health reform, we thought about the opportunities and challenges for freelancers. We started tracking the CO-OP regulations two years ago because it concerned nonprofit health insurance. When the regulation passed, we applied for funding and began working with Nancy [Barrand, senior adviser for program development for RWJF’s Pioneer Portfolio].

What difference did the Pioneer Portfolio grants make?

Whether or not you support CO-OPs, there was $3.2 billion of support available and Nancy was one of the only philanthropists who even paid attention. That’s another reason I love the Pioneer Portfolio. It has a strong point-of-view about its mission, but is open to different strategies for solving problems.

What makes this strategy a pioneering idea?

Much of the focus today is on individuals, whether they have to get insurance through an individual exchange or a policy carrier. But truly, insurance works best in groups -- always has, always will. It’s important to set up these nonprofits that understand their members, and that can tailor benefits to what people actually need and make dollars go so much further. We are introducing the ideas of affinity, solidarity, and other ideals from the mutual insurance industry that built up cooperatives. I think that mindset makes our work pioneering.

Do you think this is a “disruptive idea”?

Yes. We started with freelancers, a part of the market nobody wanted or had cared about up to that point. Now freelancers and independent workers make up a third of all employees, and the workforce is moving in that direction. So I believe we’ve made an impact on how people traditionally think about the makeup of the workforce, as well as ways to offer health insurance.

What’s next?

It’s important to understand that we are not done yet. We need to move away from the fee-for-service system, go back to medical homes with integrated care, and foster thinner, curated networks. I think it’s important that we start to collect and publicly share data with members, doctors and hospitals to solve problems with health spending. We also need to integrate alternative care structures that support healthy behaviors, such as proper nutrition and exercise. We’ve structured the health system with these as fringe benefits, when they should be mainstream benefits. Freelancers Union is trying to change the culture by offering affordable, stable benefits to independent workers—showing that it can and should be done.

For more information on how Freelancers Union is expanding health insurance choices, check out last week's blog post by Nancy Barrand, senior adviser for program development for RWJF’s Pioneer Portfolio.

New Case Studies in Innosight Institute's Disruptive Innovations in Health Series

Sep 6, 2011, 1:36 AM

 Over the past several months the Innosight Institute, a think tank that applies Clayton Christensen’s theories of disruptive innovation to the social sector, has been exploring the critical factors necessary for facilitating disruptive innovation in health care in integrated delivery systems to achieve increased quality, reduced cost, and access improvements. The work, which is funded by the Pioneer Portfolio, has already produced five case studies, including recent additions that look at processes at Grand Valley Health Plan, Group Health Cooperative, and Presbyterian Healthcare Services.

To learn how Grand Valley provides a high level of access at a low cost of care, how Group Health is employing a successful Medical Home program and how scarcity became “the mother of invention” atPresbyterian Healthcare Services pleasecheck out the full case studies here.

What does mEvidence need to look like?

Aug 19, 2011, 4:40 AM, Posted by Al Shar

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There is something magical that happens when talking about mHealth. People start believing all of the wonderful things that a phone, together with the right gadget, can do: remind me to take my medicine, monitor my vitals, inform my doctor when something goes wrong, just plain automatically keep me healthy. The last few years have seen a huge growth in cell phone companies, technology companies, governments, application and device developers rushing to deliver product in this space. Just look at the over 500% increase in attendance between the 2009 and 2010 mHealth Summit (with the 2011 meeting promising to be even larger.) Along with the hype and the hope, people are beginning to ask for evidence and to question the value of growing a collection of isolated gadgets and apps.

I’d say that mHealth is somewhere around the asterisk on the “hype cycle” model developed by Gartner.

With that as context, RWJF’s Pioneer Portfolio, together with NIH, NSF, HHS and McKesson Foundation, organized a one day event to begin the process of advancing the Science of mHealth. What does mEvidence need to look like? What are the right methods to accelerate the evaluation of the efficacy of mHealth technologies?   First steps to address this have largely been focusing on attempts to demonstrate value by using a traditional randomized controlled trial, which is often ill suited to testing the interventions that mHealth enables. (It’s interesting to note that on August 14, Paul Meier died. I’d be interested in knowing what he’d be thinking.) When we first started to plan this meeting, I wondered how interested the field would be. After all, this is the drier, academic side of mobile health. I was surprised! We had 106 responses to our call for whitepapers of which we were able to choose 23. The demand for attendance was such that NIH had to arrange for a webcast.  Perhaps looking at transforming the way conduct research [in light of new technologies] is not so dry after all. While the attendees were predominantly US-based, academic, international and corporate interests were represented. The outcome was even more surprising. The group agreed that this was a good and important direction, that we needed to have a collaborative, ongoing and forward looking agenda and that the Science of mHealth was critical to achieving a high enough plateau of productivity. The group will soon issue a statement of direction and commitment, publish the key outcomes of the meeting and develop a longer-term agenda. We are also developing an online community so that we can keep the discussion going. In a couple of weeks the webinar will be available for people who missed it and we will work to keep the groundswell moving.

I’d be remiss not to include the fact that closely aligned is the ideas and ideals of Open mHealth and the work of Pioneer grantees Ida Sim and Deborah Estrin. Not only were they and a number of people in the open mHealth area participants, they organized a second day to help formulate how they were going to develop and move forward.

This is important and people are paying attention. One way that you can help is to respond to the request from the NIH Director’s Common Fund, which is designed to fund transformative research that is of interest to the health community. The Common Fund officials are looking for the community (that is you!) to weigh in on new ideas for funding. Go here to add your comments.

Tim O'Reilly to Host 'Unconference' for Health, Tech Leaders

Dec 2, 2010, 5:11 AM, Posted by RWJF Blog Team

Today we announced a grant to O’Reilly Media  to  sponsor the Foo Health Camp in 2011, a cross-discipline, immersive, informal 'unconference' that will take advantage of a growing interest in applying Web 2.0 and open-source thinking in health care to spark ideas that can expedite changes in the ecosystem of health care services. This event is being announced on the heels of last summer’s O’Reilly Open Source Convention, where we helped sponsor the event’s first-ever health track. A full report of that event’s takeaways is now on our Web site.

The Foo Camp-unconference format was pioneered by visionary Web leaders Tim O’Reilly and Sara Winge of O'Reilly Media. O’Reilly Media is a leading technology publisher, conference organizer and supporter of the free-software and open-source movements (Foo stands for “Friends of O’Reilly). The format, in which attendees design the agenda on the spot, produces more brainstorming and group problem solving than formal presentations – which is clearly conducive to catalyzing the type of outside-the-box thinking needed to transform health and health care.

This health camp will be an invitation-only meeting, bringing together about 150 key players from health care and emerging technology, including researchers, funders, health care executives, software developers, entrepreneurs, journalists, policy experts, thought leaders and Robert Wood Johnson Foundation team members.

We will be sure to fill you in on more details as they become available, including how to participate in the conversation via social media.

For more on Tim O’Reilly’s vision on how technology will change health and health care – and why O’Reilly Media is jumping into the field – you can watch his interview with Pioneer Team Leader Paul Tarini below. Then leave a comment and let us know what you think!

Time to Accelerate Innovation: Takeaways from this Year's mHealth Summit

Nov 10, 2010, 6:03 AM, Posted by Al Shar

I just returned from the mHealth Summit in Washington, D.C. We’ve been sponsors of the event for 2009 and 2010 – both years it’s been held. Last year there were about 400 people who attended. This year there were about 2,500, including prominent guest speakers like Francis Collins, Bill Gates and Aneesh Chopra, among others. There was also a large hall with lots of exhibitors and an extensive poster session. I guess this means that means mobile health is coming of age.

I liked it a lot, but not for the reason you might think. At most of these types of events the presentations tend to expand on the great things that are going on in the field. Here there was a good, healthy dose of skepticism. And there’s a lot to be skeptical about. There are the “show me” skeptics, the ones that ask for evidence that it actually works. There are the regulation skeptics, the ones who know the problems in getting devices approved by the responsible government agencies. There are the “disruptive innovation won’t work here” skeptics. There are the “who will pay for it?” skeptics, not to mention the standards, open source, proprietary, silo, etc. skeptics. It makes my head spin and wonder how we’ll ever get there.

There are two reasons I’m still optimistic. First, in spite of all this, the field is growing and there are big players in the field. Second, many of the issues are starting to be formally addressed at what seems to be appropriate levels. That’s good. There is an area where I think more can be done, and that’s in developing better methods for validation and evidence. There’s still a huge emphasis on the traditional clinical trials model, which sets up a fixed and structured experiment, collects data over a period of time, consolidates and analyzes the data at the end of the trial, and, after a long period of time (maybe five years), reports the outcome.

The field shouldn’t have to wait five years to understand the effects of what by then will be an obsolete intervention. In addition, this is a field where there should be continuous improvement, where tinkerers thrive, where prototypes are the rule. It makes little sense to freeze development when you learn something that will make it better. One solution might be the type of adaptive trial that pharmaceutical companies are investigating. This is one where results at various stages in a trial can effect changes in the trial model. You might change the sample size, the target population, the delivery method, the formulation, etc., based upon analyzing data internal or external to the experiment. Analysis of this model is complex but can be manageable. In the end you should be able to deliver a safer, more effective product sooner.

That’s the germ of one idea for being able to develop an evidence base for mHealth quicker and better than today. These are my thoughts. I’m sure that there are smart and thoughtful people who have others.