Wednesday, August 9, 2017

What's Wrong With Healthcare


Our health care system in the US is state-of-the-art.  However, the way doctors, hospitals, insurance companies, and patients communicate is stuck in the 20th century.   While it has died a quiet death everywhere else in the world, in the medical field, the fax machine still reigns as king. Yabba-dabba-doo!

A lot of people have spilled a lot of ink in recent years about what's wrong with our healthcare system.   Let me spill a little more.  For the most part, I have not had much interaction with our healthcare system, other to visit the doctor on occasion and get a prescription filled.  I never gave it much thought.  I paid a lot in health insurance premiums, but didn't take out much in terms of services.

My recent health problems have increased my exposure to the world of healthcare and it is interesting to observe.  Years ago I wrote a patent application for a number of doctors out in Arizona, who were trying to develop an automated system for managing healthcare records.  It was a pretty ingenious invention, as it would put all records online and carefully monitor who had access to which records at what level.  A doctor could automatically send prescriptions to the pharmacy and then the pharmacy would notify the doctor when the prescription had been filled.  Apparently, patients not filling prescriptions is a big problem in medicine.

And since then, some of these ideas have been adopted in the medical industry - and it is indeed an industry.  For example, I went to an emergency care place once to get a prescription for an antibiotic when I had a diverticulitis attack.  The doctor was using a pad device and had all my data on there and was able to enter the prescription into the pad device and have it electronically transferred to the nearest pharmacy.  It was all very automated and efficient and really the way it should be.

When my regular doctor passed away, we were given hard copies of our medical records which were all handwritten.  Like most small practices, she had a wall of paper files in her office and everything was done manually on paper.  Many smaller practices still do this today, as automated systems are very expensive.

It is the same problem for the small firm or solo practitioner in the law business. There are companies that offer highly automated docketing and other systems which automatically generate reporting letters and other legal documents for you, but they can cost upwards of $20,000 to $50,000 a year or more.   I simply could not afford such a system.  However, during my brief tenure with the odious big law firm, I did help set up their system, which they had paid dearly for but were not using to the full extent.   And I suspect this is a problem for many medical practices - they are "too busy" to figure out how all the automation features work, so they use the basic parts and do everything else manually, which creates the "busy" which prevents them from automating.

And  I am sure that is one reason my former doctor did not have an automated documentation system - it was just too damn expensive and too hard to learn.  She grew up in the old school where everything was on paper and she saw no reason to change, particularly when change would be hugely expensive and require a lot of training of her staff.

Today, everyone communicates electronically, either through cell phone - although not usually by voice or even email, but through texting and other messaging systems, and apps.  I can order a pizza through a cell phone app and have it delivered to my house or make one click on Amazon order a new hot water heater for my camper.  But for some reason communications in the medical industry are stuck firmly in the stone age.

From the doctor's office, to the insurance company, to the hospital, the telephone call and the fax are still king.  My doctor's office has an enormous fax machine constantly being jammed with papers by the clerks who are sending off paper written forms to the insurance company for approval.  It is almost comical, as they have their credit card machine hooked up to the same phone line (another relic from an earlier era) and they try to process co-pays on the credit card machine at the same time they are sending faxes for pre-authorization of medical procedures.

The clerks at the doctor's office are named Tiffany, Crystal, and Amber and are all blond and have big bazooms.  They were not selected for the size of their brains.   They literally cannot figure out why the credit card machine doesn't work when you are sending a fax, but they think the two might be related.   And they all have that horrible Georgia accent, not the charming accent of a Southern Gentleman or Southern Lady, but the grating noise of the trailer park.   So far, I have not been charged a single co-pay, which brings the tab to $225.  If the doctor knew how much money he was leaving on the table he would be livid (Office visits are $140, of which BCBS pays $65 - he's losing more than 50% of his income to incompetence).

I find this mind-boggling, as the practice actually has a website that was hosted by Square.  You know Square, that company that processes credit card transactions at the craft show and does it so seamlessly and effortlessly, sending you an email confirming the credit card charge.  For some reason my doctor has a website managed by Square, but they don't have a Square payment processing system for the co-pays, instead relying on a creaky old dial up credit card machine that spools out a thin paper receipt for manual signature - when Tiffany and Amber get it to work.

I'm not taking a piss on this particular doctor, it seems that most medical offices have antiquated communication methods.  When I called Blue Cross to find out what was holding up this procedure (which is not scheduled until Friday at this point) I was told that the approval was given within 24 hours.  However the staff at the doctor's office delayed nearly 48 hours, by not sending in the paperwork in a timely manner (again, by fax) to Blue Cross for approval.  Then, the office staff waits for Blue Cross to fax back a piece of paper with approval instead of sending it instantaneously over the internet.    And in most cases, the one fax machine is so busy, it takes forever for them to send or receive faxes.

Blue Cross was very efficient in processing the request, once it was received.  But even their systems for communication are also very clunky and antiquated.  The verbal telephone call is still the primary method of communication with Blue Cross, that and ubiquitous fax machine.   While waiting on hold with Blue Cross to talk the actual person, I was exhorted to fax my requests to their fax number. Again, I find this almost amusing in its antiquated notions, as no one actually uses faxes anymore except perhaps the medical industry.

And it's not like none of these participants in the medical industry don't already have websites or internet interfaces.  Blue Cross has an extensive website which is very clunky and difficult to use, although I've noticed it's getting better with time.  They claim they update their doctor search engine on a daily basis so when you look for which doctors accept your plan, the data should be relevant and current.  In the past, the site was almost useless as it would list doctors that were accepting patients and accepting your plan, and you would call them and find out they were accepting neither.

The problem is, is you can really do very little with the site.  You cannot send any requests or do much other than pay your bill.  You cannot communicate with anybody regarding medical issues, and perhaps this is part of the HIPAA regulations or some other Federal Regulations or privacy concerns. In the medical industry, it seems people are paranoid about somebody finding out that you have bad knees or gout or perhaps a sexually transmitted disease.  I'm not sure why people are embarrassed by illness, but apparently it is right up there with sexual peccadilloes as being the number one source of embarrassment for most human beings.

In fact when visiting the doctor's office, we were required to sign a form authorizing who could see our medical information, including even our spouses.  Believe it or not, the doctor and the nurses reported that some people don't want their own spouse to know about their own medical conditions. That struck me as very, very odd, and sad at the same time.

It's been exactly a week since I had my stress test and at which point the doctor recommended the heart catheterization.  This has been a week waiting for Tiffany and Amber to fill out paperwork and  faxing it back and forth order to get an appointment.  The doctor wanted to perform the test the next day if possible or the day after, however the clerical staff informed him that it would take "at least a week" to get approval from Blue Cross which turned out to be a lie.

I believe the clerical staff was using Blue Cross as a whipping boy to cover up their own malfeasance.  Since nobody actually bothers to check with Blue Cross to find out the status of request, the doctor's staff can claim the delay was not their fault.  However, I've documented that the staff waited at least 24 hours in one case and 48 hours in another, before sending a request to the insurance company.   Blue Cross approved the procedure the same day and in fact uses an outside service (AIM) to expedite these matters.   Once Blue Cross approved the procedure the doctor's staff delayed in scheduling the appointment as well.  We could have had this procedure done five days ago if the staff have been on their toes.  They chose not to be.

What is needed in the medical industry, is a seamless medical information system that can process data and transmit it back and forth between health insurance companies, the government, pharmacies, doctors, doctors offices, specialists, and patients.  Much like the system proposed by my client many years ago, such a system would allow everyone to communicate back and forth in a effortless seamless manner and speed up the process and reduce the costs of medical care.

Of course, the question is, which system do we use?  If one vendor is chosen by the government or other agencies to process this data, it could be problematic.  On the other hand, a government-run data system doesn't sound like a the most efficient way getting things done.

I raised some of these concerns with my doctor, and he professed ignorance as to how the front office was run at his own practice.  He said "I don't get involved in the money issues, as I don't want it to affect my professional opinions."  I thought this was short-sighted, as the money issues are very important to everybody in the chain including himself.  If his office is inefficiently run and they lose money, he could end up going out of business or making less money than he thought he would be -  having to pay off all those medical school student loans.

What I discovered running a law practice was that knowing the law was only half the business.  You could be a superstar lawyer or superstar doctor and still failed miserably if you're not collecting your billing from the insurance company, or getting your co-pays for your clients and keeping an eye on the bottom line.  Unfortunately this attitude toward expenses and income seems to be prevalent in the medical field, which is why doctors and hospitals merely raise prices when their costs go up and do not make much of an effort at cost controls.

Blood tests are a case in point.  Again, it's almost comical, but the results of laboratory testing appear on a printed piece of paper which is mailed to you and mailed to the doctor, or perhaps sent by fax. Nobody sends anything electronically by computer.  Even the test request was done on paper.  In my last test, they ran a complete panel which cost over $1,300 of which I had to pay $36 of.  BlueCross picked up the rest which means they lost my month's premium in the deal.

The reason why the full panel was run was that the lab request by the doctor was on a photocopied sheet of paper with which he checked off boxes using a pencil.  This is really high-tech stuff here. The lab claimed they could not read the document and therefore ordered a full panel, which was no doubt convenient for them as they got to charge Blue Cross for a lot of tests I didn't need, including hepatitis A & C, for which I was vaccinated for many years ago, when we went to Mexico.

Again, this is an area where savings would be found, if the doctor was using a pad device and there was a commonality of software with the laboratory and the hospital and other participants in the medical field.  He could tick off which test he wanted, which would be very clear to the blood lab. It would have saved close to $1,000 on the blood test that I recently had done.  Again, no one cares, as they just charge the insurance company.

The question remains, why hasn't the medical industry upgraded to more electronically-based information systems which would no doubt streamline things and improve productivity and save an awful lot of money and time. I think the answer lies in the fact that it's not a consumer-driven industry.  Both Amazon and eBay understand that if it's too difficult for a user to click on the icon and purchase a product they will navigate away from the page and the merchant will lose the sale. There is a strong financial incentive to make things streamlined and easy in the commercial field.

With medicine, you largely have a captive audience.  People come to the doctor when they're not feeling well and they don't usually shop around on doctor, based on price.  In fact, there usually isn't much of a choice in many parts of the country as many doctors are no longer accepting patients or will no longer accept your insurance.  You go to the doctor you can go to and accept whatever terms they give you.

Since insurance companies will pay whatever the doctors charge, for the most part, there's no incentive for the doctors to keep costs down.  It is just like a government contract with Lockheed on a cost-plus basis.  They merely do whatever it is they feel they need to do, and then charge the insurance company that amount, plus an appropriate profit margin.

But that is a larger problem that will take a lot longer to solve and be far more difficult to figure out. In the meantime, it seems that having a better communication systems would be low-hanging fruit and we can go after.  There's no reason we should be using paper forms, phone calls, and fax machines in the year 2017.    There is no reason it should take a week to approve and schedule a procedure as life-saving as a heart catherterization.

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