Identifying Issues and Looking for Solutions

Earlier today I posted on our society’s reaction to the Brian Thompson assassination. I want to take this opportunity to offer some facts for consideration as we look to solve the ills of our healthcare and health insurance delivery systems.

• There is a foundational push-pull relationship between providers and payors. Contractual negotiations are often contentious. The contracts are also poorly written around what is allowed to be billed, and what will be paid. The same is true around authorization of care. Inevitably, the patient/member often? gets stuck in difficult, confusing, and ambiguous conditions at a time when they should instead be receiving support.
• Providers of care are not always right in the testing and care that they wish to provide. Quality of care varies among individual physicians and health systems, as well as by condition. One of the key shortfalls of the payors is the development and deployment of insightful quality metrics by provider and system, so that patient/members can be directed to the most appropriate provider group and site of service. Providers often chafe at quality metrics and all too rarely discipline their own when they become aware that a provider is subpar. This creates significant inequities leading to an inappropriately tiered health system.
• Payors are running highly antiquated adjudication systems whereby; complex care management and accompanying billing structures are “gummed up” in the works. The payors have neglected to adequately update their platforms for a number of reasons, not the least of which is the cost and operational risks of migrations from one set of platforms to another. The time for these investments is long overdue.
• Providers in health systems ?undertake revenue cycle enhancements in order to optimize payments from payors. The payors utilize “Payment Integrity” tools to offset the actions of providers. The patient/member becomes the ping pong ball between the two.
• Most health systems are hardly running flush with cash. This is in no small part due to reimbursement levels for government plans, as well as the health system’s own failure to realize true efficiencies from the horizontal and vertical consolidations that are occurring. This also combines with undue administrative burdens created by the aforementioned back and forth with the payors.
• Commercial plan sponsors and their patients/participants pay a tax to support the below breakeven reimbursement levels of? government programs. Plan sponsors and their patients/participants are bearing an undue burden from a financial, administration, and experience standpoint, because of their criticality in the solvency ?of both payors and providers.
• Approximately 80% of commercial plans are self-insured.? While payors are certainly making a profit on these plan sponsors, ?the profit is not tied to the declination of claims. In fact, their profit margins would rise if they “cut and paid” every claim that came in the door. Commercial plans and their patients/participants can barely afford costs as they exist today, removing needed/appropriate controls would only intensify some of the issues at hand.
• The entire supply chain of healthcare bares consideration when we are looking to solve for the issues at hand. This includes a wide range of factors, such as something as simple of the cost of durable medical equipment and medical devices, as well as the reasons for a shortage of nurses and primary care physicians.

This blog is not meant to be all encompassing. There are a number of other significant issues and considerations that I neglected to mention. Healthcare comprises over 20% of our GDP. The enormity and complexity of the issues at hand require leadership, alignment, and accountability. We cannot change everything at once but there are some logical first steps.