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 insurance. Lengthy tales brief: though – surprisingly – over 80% of insured adults charge their medical 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 can 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 “engaging in by complicated means what seemingly could possibly be completed merely.”
Boy howdy.
Medical insurance is many individuals’s favourite villain, one which many wish to do with out (particularly medical doctors), however let’s not cease there. Healthcare is filled 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 generally known as intermediaries and carriers). So do employers who’re self-insured (which is the overwhelming majority of personal medical insurance), hiring third occasion directors (who might typically even be well being insurers) to do community administration, claims cost, eligibility and billing, and different duties.
Even insurers or third occasion directors might subcontract to different third events for issues like supplier credentialing, utilization evaluation, or care administration (in its many types). Take, for instance, the universally reviled PBMs (pharmacy profit managers), who’ve carved out a giant area of interest offering companies between payors, pharmacies, and drug firms whereas elevating growing questions on their precise worth.
Doctor practices have lengthy outsourced billing companies. Hospitals and medical doctors didn’t develop their very own digital medical data; they contracted with firms like Epic or Cerner. Well being care entities had hassle sharing knowledge, so alongside got here H.I.E.s – well being info exchanges – to assist transfer a few of that knowledge (and HIEs at the moment are transitioning to QHINs – Certified Well being Data Networks, because of TEFCA).
And now we’re seeing a veritable Cambrian explosion of digital well being firms, every pondering it could possibly 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 dangerous. Or, considered from one other perspective, add much more complexity to the Rube Goldberg machine.
On a current THCB Gang podcast, we mentioned HIEs. I agreed that HIEs had been developed for a superb cause, and had completed good work, however on this supposed period of interoperability they need to be attempting to place themselves out of enterprise.
HIEs recognized a ache level and located a option to make it rather less painful. To not repair it, simply to make it much less dangerous. 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 nicely.
Not like a real Rube Goldberg machine, although, there isn’t a actual design for our healthcare system. It’s extra like evolution, the place there are not any type factors, no effectivity objectives, simply credit score for survival. Certain, typically you get a cat by 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 dangerous for sufferers, dangerous 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 a substitute of creating 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, far more efficient, and far cheaper. Sadly, we not solely don’t have such a magic wand, we don’t even agree on what that system ought to seem like. We’ve gotten so used to the complicated that we are able to not see the straightforward.
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 recommendations for all of the innovators in healthcare:
- In case your answer makes sufferers fill out another type, log into another portal, make another cellphone 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 info that’s going to be shared to assist sufferers or clinicians, please rethink.
- In case your answer solely focuses on a point-in-time, reasonably than serving to an ongoing course of, please rethink.
- In case your answer is designed to extend income reasonably 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 decreasing/eliminating the necessity for one thing even greater within the system, please rethink.
- In case your answer steers care to sure clinicians, in sure locations, reasonably than in search of the most effective take care of the affected person in the most effective place, please rethink.
- In case your answer provides prices to the healthcare system with out uniquely and particularly decreasing 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 certain all these innovators assume their thought could be very intelligent, and lots of are, however keep in mind: simply because an thought 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 guess is that normally they’re including to it.
So, yeah, I agree with Mr. Levitt and Dr. Altman that medical insurance ought to be much less complicated. Similar to every part 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.
