Healthcare in America

A Conversation with Joel Portice

Verisk Review interviewed Joel Portice, who recently became president of Verisk Health, on many of the major issues confronting the healthcare sector today.

Verisk Review: With the presidential elections now behind us, for all intents and purposes, the Affordable Care Act (ACA) is here to stay. What in the bill do you see as having the greatest effect on the healthcare industry and, indeed, the country as a whole?

Joel Portice: Some of the measures funded by the ACA regarding payment reform as well as expansion of other quality incentive programs have the potential to be truly transformative as they begin to show results and are more widely adopted. In many ways, the ACA formalized changes already occurring in the industry and provided a regulatory and financing framework to test some of those concepts more fully so that the industry can learn and adapt. The launching of Accountable Care Organizations, the expansion and formalization of a ratings program that will reward high-quality plans, and readmission penalties are all examples of incentives for better quality or disincentives for poor quality. For example, Medicare Advantage plans below three stars in the five-star rating will soon not only lose their bonus payments but will also be removed from the Medicare website, which many beneficiaries reference to select plans. Finally, it would be hard not to comment here on expansion of coverage under the Health Insurance Exchange programs. Bringing millions of previously uninsured Americans into the healthcare system raises tremendous challenges and opportunities for the industry and our citizens.

Verisk Review: It’s often reported that about 20 million more Americans will obtain coverage under the ACA. What are some of the struggles and concerns you see healthcare having to overcome, and what are some of the opportunities?

Portice: There are a lot of unknowns with so many new entrants to the healthcare system. Which states will formally adopt an exchange? Which will expand their Medicaid program now that the Supreme Court has effectively made doing so optional? Whether states expand Medicaid or not, how will they track eligibility between subsidized exchange coverage and Medicaid? How can the experience be made seamless for members without being overly burdensome for health plans and states?

States and health plans that participate in exchanges will have a lot to contend with in terms of the risk profile of the newly insured. And will there be enough providers to ensure that services are available to all these individuals? Some of them may have gone without care in the absence of coverage and may have numerous medical issues. We’ve all had challenges with limited provider availability and brief appointments, and I can only imagine this escalating with so many additional insureds.

On the other hand, this may spawn innovative approaches to community-based care delivery and alternative providers working in more accessible settings. Verisk Health had the great fortune of having Susan Dentzer, editor in chief of policy journal Health Affairs, deliver the keynote address at our conference in September. She touched upon a lot of these same challenges and opportunities. It was a terrific learning experience for our clients, partners, and team members.

Verisk Review: With all the various data sources available — whether claims, electronic medical records, or others — what is the key to pulling the disparate data sources together and creating more actionable data?

Portice: With all the talk of Big Data and the integration of multiple forms and sources of data, the key will be to create a flexible, common underlying architecture and rules engine that deliver consistency and reliability for end users and the various applications those users require to address their business challenges. People talk about integration of the “usual suspect” data sources, such as bills, claims, disability, and workers' comp but also such sources as preferences and social network data — all this in a quest to further refine and personalize the experience down to a “segment of one.” Who knows how all this will shake out? But we are certainly investing in the underlying platforms and rules and analytics engines to manage and use multiple data sources. We want to offer a seamless, efficient, user-friendly, and consistent experience for our clients, no matter what data sources they’re able to provide and through whatever market they’re in or business challenges they face.

Verisk Review: Speaking of business challenges, what kinds are both the property/casualty and healthcare industries facing?

Portice: The similarities are significant: Both industries, among other common practices, experience document transactions caused by an event, such as a visit to the doctor or hospital. They both possess robust historical data representative of potential future occurrences. That includes information not only on the claimant or patient but also the service provider. Understanding that information provides insight into patterns that may reveal suspect billing practices at a provider-centric level, whether in the property/casualty or healthcare industries. Both industries can also identify emerging fraud trends by matching the historical data against current behaviors. For both, the ability to control future costs and medical expenses with accurate risk identification will be critical.

Verisk Review: What opportunities do you see for the two verticals to help and/or leverage one another — for example, coordination of care, data sharing, collaboration in fraud fighting, and aggregation of data?

Portice: The ability to aggregate data while simultaneously analyzing the transactions and claims/bills is extremely powerful. Add to this a method to alter the industries’ challenges and trends proactively so that every individual can experience positive effects. If we start with the practice of viewing data-driven patterns across verticals and compare against each other to improve outcomes, we’ll find numerous other opportunities to benefit consumers.

Verisk Review: What can the two verticals learn from each other?

Portice: While both industries perform certain risk management techniques well, neither applies the broad methods that leverage the strengths of the other vertical. For example, property/casualty aggregated data across carriers long before healthcare. Now, we’re seeing an emerging acceptance of cross-payer data consolidation in the healthcare space because of the proven results of the property/casualty efforts. Conversely, the healthcare industry has delivered criteria needed to craft appropriate provider contracts that reward quality of care and take the economics beyond a model and fee schedule driven purely by volume of services — from which property/casualty could certainly learn.

Up Close and Personal

Before joining Verisk last summer, Joel Portice served as CEO of Intelimedix, COO of HealthCare Insight, and cofounder of Enclarity, Inc. and Integrity Plus Services. He is also a member of the board of trustees for Hamline University and the board of advisors for the Center for Healthcare Management and Policy of the Paul Merage School of Business at the University of California, Irvine.

Verisk Review: You started your career as a legislative assistant with Senator Tom Daschle. What spurred your early interest in the public sector?

Joel Portice: I was interested in how public policy — under the right conditions and when properly administered — affected society. I wanted to contribute to the positive advancement of the community in any way I could. I was also fascinated with politics and the machinations of the political and legislative processes of Capitol Hill.

Verisk Review: And how did you find yourself in the private sector?

Portice: I funded my graduate school education by working for Equifax Services and became interested in data analytics and how to use data and technology to create powerful and reliable decisions across multiple areas.

Verisk Review: Next, you founded a company called Integrity Plus Services. How did that come about?

Portice: It was during my time at Equifax that I saw an opportunity to fill a market gap around aggregating data and automating analyses to detect problematic claims. This was all done retrospectively, but we saw a way to incorporate the historical results in a prepayment manner. No one else was doing that at the time. UnitedHealth Group became interested in the business and ultimately acquired it.

Verisk Review: What lessons have you learned from starting your own companies that stay with you today and that you apply here at Verisk Health?

Portice: Focus and execution are keys to operational success. I’ve seen many smart entrepreneurs with good ideas fail because they try to do too much and become distracted. You have to be disciplined enough to stick to your core; focus on those few areas that matter to your customers and business; and be prepared to walk away from other ideas that don’t benefit your organization, regardless of how interesting they might be.

Verisk Review: And finally, tell us one thing about yourself that would surprise most people.

Portice: Not long ago, I published my first novel, titled Paper Bridges, which is available on Amazon.com.