Interview with B.P. Fulmer

When he's not solving another industry problem, BP Fulmer, a former commercial airline pilot with many years of experience in cash management banking and healthcare, is running ACS' Commercial EDI Gateway. As the Executive Director of this program, BP has seen first hand the need for integrating banking systems and know-how into the healthcare system. He often likens his journey starting with a 15 year stint in banking to "entering a dark cave" when he started his work in healthcare. BP has managed state Medicaid programs and energized a new "EDI Gateway" program at ACS that provides outsourced services to health plans and others.

Besides all this, BP serves as the President of the National Medical Banking Institute series, an educational arm of the Medical Banking Project. Under his guidance, the Institute formed a new President's Council with leading domain experts. We asked BP what he thinks about medical banking in general, and what he hopes to accomplish at the Institute.

BP, do you think "medical banking" represents a paradigm shift in electronic processing in healthcare?

There is no doubt in my mind that banks are poised to become a major influence in the movement of healthcare records and transactions. The infrastructure is already in place to provide data and transaction switch and routing services over some of the most secure and efficient communications networks in the world. While there will be some needs to modify the transaction sets and the capability of these networks to accommodate them the connectivity to the healthcare provider community already exists. The impediment that exists today are the banks themselves. There exists virtually no healthcare transaction domain experience in banks and banks, by nature, are cautious to move into markets that they do not understand. By the way, this is good. It is one of the reasons why banks enjoy such high levels of consumer confidence.

How do you think the banks view the idea of medical banking?

Some are totally bewildered, others are like deer in the headlights not knowing which way to go, and a few (very few) have figured it out that because of the evidence in the farm there must be a pony somewhere. But, I do believe that banks, in general, recognize healthcare as perhaps the last business sector there is to conquer and there are literally trillions of dollars at stake.

What kinds of improvements in healthcare do you see coming out of the medical banking 'movement'?

Most of the improvements are tied to making the administrative side of healthcare transaction process and settlement more efficient. The real time nature of the banking and credit card networks will support the move to online adjudication (or near adjudication) of claims, eligibility, deductibles and status a reality. For PHR/EHR to have a chance of achieving their full impact on the delivery of healthcare we must have the real time networking capability that banks already enjoy. It makes sense for us to turn to banks for leadership and networking expertise.

What do you think the Medical Banking Institute should offer to the industry at large?

The Medical Banking Institute is the only place of which I am aware that brings together some of the best minds from healthcare and financial services to create an open forum for the dissemination, discussion, study and debate of the various alternative resources and methods of streamlining the movement and processing of healthcare transactions and data that exist today. But more important, it is the only forum actively involved in fostering and supporting the development of solutions for the future. Solutions that must involve the cooperative interaction of banks, clearinghouses, practice management vendors, providers and payers.

What's the most exciting thing, in your opinion, that is happening at the Medical Banking Institute in March?

Aside from the fact that this will be the largest and most successful Medical Banking Institute in its five year history I am excited about the diversity of the organizations that well be represented as attendees and sponsors.

Also, there will be several sessions dedicated to the impact of CDHC on the healthcare market. I am fascinated as to how CDHC (otherwise know as "The great risk shift to providers and consumers") has almost dominated the national healthcare debate. (I suppose RHIO's and PHE/EHR are right up there as well.) Two years ago I was concerned that high deductible plans would create financial burdens on consumers and providers resulting in "push back" from both groups. It didn't take a genius to figure that one out. But what is interesting is that payers and employers are beginning to feel this "push back" because providers are beginning to question whether it is worth taking patients on these high deductible plans due to the credit risk and their bad debt experience with these patients. The assumption is this could threaten "in plan" provider access and the relevance of payers to provider networks.

About B.P. Fulmer

B.P. Fulmer joined ACS three and one-half years ago and currently serves as Executive Director of ACS Commercial EDI.  Mr. Fulmer has served in this position since November 2004.  In this position he has been charged with developing a commercial services unit that operates as part of the ACS EDI Gateway.  The ACS EDI Gateway processes over 750 million EDI transactions a year and is connected to 61,000 submitters representing over 250,000 providers. Mr. Fulmer has 17 years of banking and financial services management experience plus 15 years healthcare transaction processing management experience.  Mr. Fulmer's banking experience includes serving as a bank examiner, check transit operations, correspondent banking, Comerica banking, electronic funds transfer and running cash and treasury management services at two regional banks.  Mr. Fulmer's healthcare transaction management experience includes responsibility of running the Medicaid Fiscal Agent operations for ACS and First Health Services in Florida, Georgia, Tennessee and New Mexico (twice).  He has run a medical billing services company and an internet based practice management software development firm.  This experience gives Mr. Fulmer both the payers and providers prospective of the healthcare transaction.  Mr. Fulmer brings a unique prospective to the Medical Banking Institute as President (2005- current) in that he has extensive experience in banking and healthcare and has a track record of innovation in both fields.

Dr. Jonathan Gold - Health Record Banking System Final Report

By John Casillas

Dr. Jonathan Gold, MD, MHA recently completed a new report on what he feels is an "imperative" in healthcare today; namely, adoption of Health Record Banks (HRB). His work in this area is impressive. He has interviewed many experts around the country to identify potential snafus in adopting the model that while using the term "bank" in its name, can actually be implemented external to banks as well. Dr. Gold is presenting his latest report - "Critical Issues In The Development And Implementation Of A Health Record Banking System" - at the Fifth National Medical Banking Institute.

In preparing the agenda for the 5th National Medical Banking Institute I had the opportunity to speak to a number of HRB enthusiasts. I consider Dr. Gold's work, and the work of Dr. Marion Ball (IBM/Almedaen Institute) and Dr. Amnon Shabo (IBM/Haifa, Israel) to be the most authoritative in this area.

I am concerned that as we talk about this concept, and others where the bank is being utilized for eHealth infrastructure, that we are at the same time embracing the serious privacy, security and confidentiality issues that go hand-in-hand with this approach. While Gold makes this a clear priority, within the context of the commercial banking industry we must remain vocal that banks take HIPAA very seriously; at least this is definitely the case with MBProject member banks.

In 2001, the Medical Banking Project announced the possibility that banks can form a new eHealth ecosystem that can improve healthcare. I had been working on this since 1996 related to administrative messaging through bank systems as a new recurring fee model. In 2001, we faced a lot of pressure from banking associations when my White Paper on HIPAA's Impact on Lockboxes was published in the Journal of Healthcare Administrative Management and the International Privacy Association's newsletter. Like any other segment, banks were reticent to embrace HIPAA - clearly a first step towards lending their significant investments in technology, systems and process for creating a digital ecosystem for healthcare.

Today, our member banks are working on a number of medical banking models targeting an eHealth ecosystem. As we pursue this goal, we are glad that at a time when we embraced HIPAA as a foundational stepping stone for banks in healthcare, that the privacy groups rallied around MBProject. Many privacy advocates continue to argue that more needs to be done and these voices are once again being heard in DC; and they need to be heard by the medical banking community as well. Going forward, our goal is to keep privacy advocates in our dialogue and industry direction.

Dr. Gold recently wrote the following comments to MBProject and we are reprinting here:

Dear Mr. Casillas,

Last year, as an NLM post-doctoral fellow at Johns Hopkins School of Medicine, I discussed with you the use of a banking model for storing personal health records. I have recently concluded my final report for this project and would like to share this with you and thank you for your participation.

Since your involvement in the project, a number of interesting events have occurred:

1) U.S. Sen. Brownback and U.S. Rep. Ryan have introduced proposals in their respective houses of congress regarding health record banks (U.S. Senate Bill (Proposal):S.3454.Independent Health Record Bank Act of 2006; U.S. House of Representatives Bill (Proposal): H.R.5559),

2) IBM Systems Journal has published the health record banking white paper in a special health issue (Gold JD, Ball MJ. “The Health Record Banking Imperative: A conceptual model”. IBM Systems Journal, Vol 46, No 1, 43-55 (2007). Available from http://www.research.ibm.com/journal/sj/461/gold.pdf.),

3) Discussion of health record bank models appeared in the HIMSS journal (Ball MJ, Gold JD. Banking on Health: Personal Records and Information Exchange. J Healthc Inf Manag. 2006 Spring;20(2):71-83.),

4) The HRBS proposal will be presented at the 5th National Medical Banking Institute in March (http://www.mbproject.org/5MBI2007.php), and

5) Washington State's Health Information Infrastructure Stakeholder Advisory Committee has recommended the adoption of a competitive banking model and personal health records for data exchange within the state.

I want to thank you again for your time and your help in this research project.

Most respectfully,

Jonathan Gold
Dr. Jonathan Gold, MD MHA
office: (303) 926-2451 or 1-800 752-4143 ext. 2451
P.O. Box 270249, Louisville, CO 80027

About Dr. Jonathan Gold, MD MHA

Dr. Gold is a physician analyst for McKesson Provider Technologies. He recently completed a Master of Science degree as a National Library of Medicine post-doctoral fellow in health sciences informatics at Johns Hopkins University. He received an M.D. degree at Ben-Gurion University in Beer Sheva, Israel in 1990 and gained board certification in pediatrics in 1997. Subsequently, Dr. Gold served as a primary-care pediatrician and as the director of the medical quality-assurance unit for the Maccabi Health Service's Negev region. In 2001, he completed a Master of Health Administration degree at Ben-Gurion University. A pediatrician with close to a decade of primary-care practice and medical quality-assurance experience, Dr. Gold is focused on the development of the consumer-oriented, electronic Health Record Banking system, the practical needs of the health-care provider, and the considered goals of a comprehensive health-care strategy.

Interview with Roy Ramthun

The editors of MBlog (The Medical Banking Blog) caught up with Roy Ramthun, a man who seems busier these days than when he was an economic advisor to President Bush, to find out what he is doing today.

Questions:

1. Roy, what is HSA Consulting Services and how are things going for you? 

Things are going well.  I started HSA Consulting Services to focus on Health Savings Accounts (HSAs) and consumer-driven health care issues.  We are trying to make sure every American knows about the opportunities HSAs present and assist them with implementing an HSA program or benefit plan at their company or financial institution.  We also help connect people with professionals who can help you find qualified health insurance or account services. 

2. If you had a single, crisp message about how CDH could impact healthcare what would it be? 

CDH gives patients a financial reason to care about whether they are getting good value for their health care dollar.  People spend their own money differently than someone else’s money, and the CDH experience is showing that the same applies in health care.  As patients and consumers become better equipped with information, the decisions they make about their own health care will revolutionize how health care is delivered and financed.

3. Do you think the stakeholders are aligned to make CDH a reality or is more work required in this area?

I believe more work is required.  Most people have not experienced or participated in a CDH plan so it will take some time to align all the stakeholders to where they need to be.  After we see about 10% penetration by CDH plans, things will happen much more quickly.

4. In your view, what can banks do to improve healthcare? 

Banks bring a different mindset to the financial transactions behind health care, one of simplicity and transparency.  The ATM machine revolutionized banking in this country and we are now use to simple, concise monthly bank statements for our accounts.  Compare that to most claim processes for health insurance today, some of which are incomprehensible.  Banks also offer an alternative mechanism for providing financial protection which help remind us exactly what insurance is.

5. Roy, we asked BearingPoint to come up with marketplace questions. What is your current thinking about:

-- What do you think will be the impact to the financial institutions (FIs) of the Medicare MSA pilots? Do you think that many of FIs are fully aware that with these accounts, it is the carrier that chooses the bank?

I don’t think most FIs are aware of these plans, but this is the first year they are being offered to Medicare beneficiaries and only 2 companies are offering plans in 39 states plus the District of Columbia.  While the carrier chooses the bank, the senior can also transfer their funds to another institution.  The greatest opportunity will be for institutions that have customers that already have an HSA when they enroll in Medicare in the future.  These customers will be looking for FIs that can handle both their accounts and manage their assets.

-- What do you think will be the impact of the December 06 HSA legislation as to the speed of the points below?

a. HSA enrollment levels by individuals

The combination of employer funding flexibility, higher contribution limits, FSA and HRA and IRA rollovers dramatically increase the likelihood of enrollment by individuals.  All these provisions help remove the uncertainty about switching to an HSA from a traditional plan.

b. Offering of HDHP/HSAs by employers, especially with the new flexibility in contributions across the employee base

Another huge benefit.  This gives employers an additional tool to increase adoption by helping fund the accounts of lower-income workers who might be most afraid of the high deductible plans.  Now, if the employer can fully fund their account, they have nothing to lose and could definitely be much better off than under a traditional plan.  And finally, for employers that have been offering HRAs and now want to switch to HSAs, they can roll over these funds to their employees’ HSA accounts going forward.

c. Levels of funding in individuals’ HSAs

The increased contribution limits are HUGE.  I will now be able to much more quickly build up a balance that rolls over and offers me investment opportunity.  The fact that you also don’t have to have the highest deductible plan to make the maximum contribution helps, too.  However, it also means I can increase my deductible over time and lower my premium even further.

-- What do you think is the likelihood passage of some of Bush’s new proposals:

a. Tax treatment of health benefits above/below $15,000 (family)?

While it is the right policy, the single payor advocates and labor unions are adamantly opposed.  They have more friends in Congress right now, which creates challenges for getting a bill to the President for signature.  I fear the current Congress would rather talk about the issue and take their chances on the outcome of the 2008 elections.

b. Raise HSA contribution limits?

A reasonable policy change would be to increase contributions to the out-of-pocket limits for HSA-qualified plans, as the President has proposed.  But the current leaders in Congress have other priorities they would like to spend money on first.