A reader recently send me this graphic on the costs of healthcare, which is interesting in many ways.
Created by: Medical Billing and Coding Certification
Some of this diagram I agree with, and some I do not, or at least what is implied by the information contained therein. Overall, the diagram is correct – American’s can’t afford healthcare. At least not the kind we try to provide. However, I don’t feel that the diagram really addresses why Americans can’t afford healthcare in an accurate way.
As a physician formally trained in computer science, I have the opportunity to look at today’s computerized medical record systems both from the perspective of a end user and as a software designer. It is perhaps because of this that I have been so persistently disappointed with the current state of clinical record software.
I am disappointed because despite all the fancy hardware and expensive software, our clinical records systems aren’t that much better than paper. We would think that a patient could go to any doctor and present their medical records the doctor could read them, but they can’t. We would think that it would be easy for me to get a CT scan report that was done at an outside hospital, but no. It actually has to be printed out and faxed, requiring not only human intervention and time, but if reentered into the receiving provider’s system actually converts a digitally stored report into a picture of a piece of paper, completely breaking the idea of an electronic record system. While information can be digital in one system, if it ever is passed on to someone working in another system, it becomes just another piece of digital paper. The sad truth is that despite our incredible investment in EMR systems, we have only created a massive collection of information silos, and have almost no way to transfer information between them – a system little better than the paper charts we sought to eliminate. And sadly, because these silos are hard coded and massive, innovation is stifled.
There is a very specific reason why our system operates like this, and it is that EMRs as a whole lack a common way to represent information. Each system represents medical records in its own proprietary format, and thus lack the ability to speak to each other. An thus no matter how wonderfully a EMR system represents information to its users, if information has to get out of the system, it can only be through pictures of pieces of paper.
So is there a solution to these problems? I would argue yes. But it requires a fundamental change in our paradigm – a change to a common “Model” for representing data.
Last year I wrote about a few strategies for decreasing costs in the operating room. Since being in fellowship operating many days per week, I’ve come up with a new idea, this time a bit more radical.
In Freakonomics, Leavitt and Dubner posit that in all things, human beings respond to incentives. If you want to understand human behavior, all you have to do is identify the incentives that drive them, be they emotional, financial, or social. In that vein, I wonder what incentives drive us to spend so much money on healthcare, and to waste resources when they need not be wasted.
I found a potential answer in another book, Chris Anderson’s “Free: The Future of a Radical Price” In this work Anderson investigates how an economy is affected when the marginal cost of production of a good approaches zero. Specifically, he investigates the economy surround digital goods, that while costing resources to develop, have a marginal cost of zero to produce and distribute. He proposes that in such a system, it is quite natural that the price of such goods will eventually approach zero, and if it doesn’t, the goods will be routinely stolen rather than paid for.
The corollary to this idea is the concept of optimal use of a resource when its cost is zero. That is, if one gets a real benefit from the use of a resource but it costs nothing whatsoever to use it, what is the right way to use that resource? Anderson suggests that the correct course is to use that resource to its maximal extent, and even to waste it without thinking despite diminishing returns. Read more…
Today I saw a patient for a preoperative visit and went through the ritual of “informed consent” and the signing of the surgical permit. We had decided to do a hysterectomy to treat her problematic fibroids, and she very much wanted to proceed. Having discussed the alternatives, we now had to go through the legal ritual of the surgical consent.
As usual, I discussed what we could expect to gain from the hysterectomy. There was a 100% chance that she would no longer have any bleeding, and a very strong chance that any pain that originated in her central pelvis would get entirely or mostly better. Anemia that resulted from the bleeding would improve. Other symptoms, like urinary pressure and frequency, and lateralized pelvic pain, would likely improve though it is not as strong a likelihood as the other symptoms.
We also discussed the risks. “You could have bleeding during the surgery, potentially enough to need a blood transfusion before or after surgery. You could get a communicable disease from a blood transfusion. You could develop a wound infection or abscess, which sometimes is easy to treat and other times quite complicated. Anything in the abdomen could be damaged during the surgery, such as the bowel, bladder, ureters (“which carry urine from the kidneys to the bladder” I always say), blood vessels, or other structures. Anything damaged can be fixed at the time by myself or a consultant. There is a possibility something could be damaged but we do not recognize it at the time, or that there is a delayed injury. If this occurs you might need further surgery, antibiotics, or hospitalization. Though extremely rare, you could die or be injured from an unforeseen surgical complication or complication of anesthesia.”
At this point she looked white as a sheet, as usual, and then I tempered with “but all of this is extremely unlikely, less than 1% of cases for major issues, and I have to explain it all for legal reasons. I am well trained to do this surgery and will do my absolute best for you.” I answered her questions, the consent is signed, and we had our pre-op.
A while back I published a bit about how to get insurance appeals approved. So here’s a specific example. This regards a young woman who delivered her first infant and was having trouble breastfeeding. After discharge, her physician recommended home lactation consultation services, which her insurer denied as not medically necessary. The patient’s policy did cover “skilled” medically necessary home health service , but not “custodial” care, defined as care meant for ongoing maintenance or assistance with daily living.
So here’s an answer to that (nonsense).
In a previous post I talked about how the insurance appeals process works. In this post I’ll talk about the things every doctor can do to maximize the chance that insurance appeals will go in their favor. But first, a quick review.
Coverage requests get rejected when the requested service does not fit within an insurance company’s initial guidelines for approval. This happens for a number of reasons, but usually it comes down to poor documentation or inappropriate care, or in some cases care that is appropriate but can’t be supported in the literature. When a denial occurs, the physician or patient has several opportunities to appeal this decision. The first appeal is about proving that your case does meet the insurance guidelines and that it was incorrectly rejected. The second appeal is about proving that the request should be accepted outside of the coverage guidelines. Sometimes there is another level that looks at whether the care is experimental.
Ruling the insurance appeals process – Part 1: How it all works
One thing that many residents do not know is that there are more benefits to becoming a board certified physician than just that plaque on the wall. One of these benefits is that ability to pick up a few extra hours of work here and there doing consulting for the multitude of companies that would like the opinion or expertise of a physician.
In some cases this consulting can be about products under development. Sometimes it is reviewing the work that another physician has done, perhaps for a hospital quality care committee. There is also work for some reviewing legal cases. But probably the biggest area of this work is insurance work – usually in the area of appeals.