The US Healthcare System

Madhav Sitaraman – Co‐Founder, Enlightiks

US Healthcare

7% 17.2 %

1970 2012

Share of wallet

Value Good Health

Gross Domestic Product (GDP)

US Healthcare spending

Americans Payer Providers Patients

Fee for Service

Hospital Care $ 882.3 Billion

Physician & Clinical $ 565.0 Billion

Professional Service $  76.4 Billion

Dental $ 110.9 Billion

Personal Care $ 138.2 Billion

Home Health Care $   77.8 Billion

Nursing Facilities $ 151.5 Billion

Prescription Drugs $ 263.3 Billion

Medical Equipment $   95.0 Billion

The problem

Some facts:

Healthcare spend will crowd out all spending other than defence

If city’s and towns were to report their financials for healthcare commitments, most would be BANKRUPT!!!

Millions of uninsured (~48 million Americans)

Increasing premium amounts

Sick people are being excluded / health care cost was capped

Patients with pre-existing conditions were denied insurance or had to pay heft premiums

Payments revolved around ‘Fee for Service’ and performance is not tracked

Healthcare is TERMINALLY ILL!!!!

Patient Protection and Affordable Care Act(Obamacare)

Health coverage for larger population

Continues long term care with no cap

Patients with pre-existing conditions get insurance at the same premium

Medicaid Expansion with in states to accommodate lower income groups

Healthcare Exchange for buying insurance

Individual Mandates requiring everyone to get insurance

Medicare Shared Saving Program to improve care coordination and performance

Obamacare bill is 20,000 pages long

Would be over 7 feet tall if we stacked them

Accountable Care Organization (ACO)

Population Health Management

Patients

ACO must define processes to promote evidence‐based medicine and patient 

engagement, monitor and evaluate quality and cost measures, meet patient‐

centeredness criteria and coordinate care.

Querent Overview

Readmission Management

Risk Prediction

Cost & Resource

Compliance

Patient Similarity

Profiling

Outcomes

Optimization

ClinicalPathway

Future stateOf Health

Disease Progression

Preventive Healthcare

Solution ‐ Querent

Models

Hospital Systems

Pattern Recognition

Big DataDomain Expertise

Machine Learning

External Sources

Claims & Insurance Data

Areas for innovation

Care Coordination Care Delivery

Security Innovations

Education Social Media

Healthcare Security & Privacy

HIPAA HITECH MU

94%

Data Breach

48%

Billing & Insurance records

20%

Prescription Details

24%

Payment details

13%

Monthly statements

48%

Medical Files

2769Avg no. of 

records stolen

Q & A