By KIM BELLARD
Larry Levitt and Drew Altman have an op-ed in JAMA Community with the can’t-argue-with-that title Complexity within the US Well being Care System Is the Enemy of Entry and Affordability. It attracts on a June 2023 Kaiser Household Basis survey about shopper experiences with their medical health insurance. Lengthy tales brief: though – surprisingly – over 80% of insured adults charge their medical health insurance as “good” or “glorious,” most admit they’ve issue each understanding and utilizing it. And the individuals in honest or poor well being, who presumably use well being care extra, have extra issues.
Medical insurance is the goal on this case, and it’s a honest goal, however I’d argue that you could possibly choose nearly any a part of the healthcare system with related outcomes. Our healthcare system is ideal instance of a Rube Goldberg machine, which Merriam Webster defines as “conducting by complicated means what seemingly could possibly be carried out merely.”
Medical insurance is many individuals’s favourite villain, one which many want to do with out (particularly docs), however let’s not cease there. Healthcare is stuffed with third events/intermediaries/middlemen, which have led to the Rube Goldberg construction.
CMS doesn’t pay any Medicare claims itself; it hires third events – Medicare Administrative Contactors (previously referred to as intermediaries and carriers). So do employers who’re self-insured (which is the overwhelming majority of personal medical health insurance), hiring third celebration directors (who might generally even be well being insurers) to do community administration, claims fee, eligibility and billing, and different duties.
Even insurers or third celebration directors might subcontract to different third events for issues like supplier credentialing, utilization overview, or care administration (in its many varieties). Take, for instance, the universally reviled PBMs (pharmacy profit managers), who’ve carved out an enormous area of interest offering providers between payors, pharmacies, and drug corporations whereas elevating rising questions on their precise worth.
Doctor practices have lengthy outsourced billing providers. Hospitals and docs didn’t develop their very own digital medical data; they contracted with corporations like Epic or Cerner. Well being care entities had bother sharing information, so alongside got here H.I.E.s – well being data exchanges – to assist transfer a few of that information (and HIEs are actually transitioning to QHINs – Certified Well being Info Networks, on account of TEFCA).
And now we’re seeing a veritable Cambrian explosion of digital well being corporations, every pondering it may well take some a part of the well being care system, put it on-line, and maybe make some a part of the healthcare expertise rather less unhealthy. Or, seen from one other perspective, add much more complexity to the Rube Goldberg machine.
On a latest THCB Gang podcast, we mentioned HIEs. I agreed that HIEs had been developed for a superb cause, and had carried out good work, however on this supposed period of interoperability they need to be making an attempt to place themselves out of enterprise.
HIEs recognized a ache level and located a approach to make it rather less painful. To not repair it, simply to make it much less unhealthy. The healthcare system is replete with intermediaries which have workarounds which permit our healthcare system to lumber alongside. However as soon as in place, they keep in place. Healthcare doesn’t do sunsetting properly.
In contrast to a real Rube Goldberg machine, although, there isn’t any actual design for our healthcare system. It’s extra like evolution, the place there aren’t any type factors, no effectivity objectives, simply credit score for survival. Certain, generally you get a cat by way of evolution, however different instances you get a unadorned mole rat or a hagfish. Healthcare has much more hagfish than cats.
I’m impressed with the creativity of many of those workarounds, however I’m awfully uninterested in needing them. I’m awfully uninterested in accepting that complexity is inherent in our healthcare system.
Complexity is unhealthy for sufferers, unhealthy for the individuals instantly giving the care, and solely good for all the opposite individuals/entities who make a residing in healthcare as a result of if it. As an alternative of constructing ache factors much less painful, we ought to be eliminating them.
If we had a magic wand, we might remake our healthcare system into one thing a lot less complicated, rather more efficient, and far inexpensive. Sadly, we not solely don’t have such a magic wand, we don’t even agree on what that system ought to appear to be. We’ve gotten so used to the complicated that we are able to not see the easy.
I don’t have a Utopian imaginative and prescient of a healthcare system that will remedy all the issues of our system, however I do have some ideas for all of the innovators in healthcare:
- In case your answer makes sufferers fill out yet another kind, log into yet another portal, make yet another telephone name, please rethink.
- In case your answer takes time with sufferers away from clinicians, making them do different duties as an alternative, please rethink.
- In case your answer doesn’t create data that’s going to be shared to assist sufferers or clinicians, please rethink.
- In case your answer solely focuses on a point-in-time, fairly than serving to an ongoing course of, please rethink.
- In case your answer is designed to extend income fairly than to enhance well being, please rethink.
- In case your answer doesn’t acknowledge, acknowledge, report and act on failures/errors/errors, please rethink.
- In case your answer can’t merely be defined to a layman, please rethink.
- In case your answer provides to the healthcare system with out lowering/eliminating the necessity for one thing even larger within the system, please rethink.
- In case your answer steers care to sure clinicians, in sure locations, fairly than looking for one of the best take care of the affected person in one of the best place, please rethink.
- In case your answer provides prices to the healthcare system with out uniquely and particularly lowering much more prices, please rethink.
- In case your answer doesn’t have built-in mechanisms (e.g., use of A.I.) to be and keep present on an ongoing foundation, please rethink.
I’m positive all these innovators assume their concept could be very intelligent, and lots of are, however keep in mind: simply because an concept is intelligent doesn’t imply it’s not Rube Goldbergian. They should step again and take into consideration in the event that they’re including to healthcare’s Rube Goldberg machine or serving to simplify it. My wager is that often they’re including to it.
So, yeah, I agree with Mr. Levitt and Dr. Altman that medical health insurance ought to be much less complicated. Similar to every little thing else within the healthcare system. Let’s begin taking the healthcare Rube Goldberg machine aside.
Kim is a former emarketing exec at a serious Blues plan, editor of the late & lamented Tincture.io, and now common THCB contributor.