The problem with the US healthcare system is that no one truly owns the problem

We all read about the challenges of our healthcare system. But when you experience them first hand, it really hits home.

Over the last year, I was the unwitting participant in a comedy of errors. A collective failure by providers and payors to effectively manage information. These mishaps occur within hospital systems, between providers, and between providers and payors.

My personal experience highlighted several key process challenges:

• No end-to-end process oversight – current regulatory focus only touches on a limited number of areas
• No accountability between provider and payor organizations – the patient bears all the financial risk
• No digital ecosystem – paper and CD ROMs still rule the day, and the patient is the sneakernet

Let’s Start At The Beginning...

A nodule on my right lung was evident during a recent kidney stone episode. After that resolved, and per medical recommendations, I saw a pulmonary specialist.

The physician was in the approved network of my insurance company. After an initial consultation, the she ordered an MRI.

To compare images, the referring physician requested that I send the original MRI results as well.

Medical Records Access

Two months passed trying to get my medical records including X-rays and MRIs. First, the small community hospital in Georgia, sent me to their portal. It did not have the images. After some extra cajoling, I received, in the mail, a CD.

I was not able to verify the contents because it required a CD ROM player.

Turns out, it did not contain the images. It only had the medical records and the notes from the radiologist that I had already downloaded from the portal.

Referral Process

After scheduling an appointment, my insurance company pre-approved the procedure. But my work travel schedule pushed back the procedure by a few weeks.

At the time of the appointment, the radiology practice verified my address, email, and insurance.

After the procedure, the radiology provider sent the new MRI images for review.

Diagnostic Image Review

My referring physician received the images and verified the nodule. She suggested a follow-up in a year.

With nothing urgent to worry about, I put a tickler in my calendar.

So far so good.

Billing and Support System Issues

Five months after the procedure, an alert from my credit monitoring application notified me of a problem. According to the hospital system who performed the MRI, my account was past due and assigned to a collection agency. But I did not receive any written, email or voice mail communications from the hospital.

I called the hospital. Since I had recently resolved a similar issue with hospital (and collection agency) a few months earlier. I was hoping it was a simple error. But the billing department, could not find a record of the prior calls nor the resolution.

Turns out that the hospital's support ticketing system does not share inbound call records between departments (billing and collection). Plus, the hospital's billing systems contained multiple versions of “me”. Each with different contact information.

So, resolving the prior issue did not update the systems between departments.

Insurance Process Dysfunction

Over the next year, I was on no less than 12 calls with both the insurance provider and the hospital system. At least 4 times, I had both parties on the same call. Each call started with the same set of questions, the eventual escalation to a supervisor, and ended with a non-result. While the insurance company continued to say that I had no financial liability, the hospital surely did not agree.

First, the insurance provider could not (or would not) process the claim. The hospital had submitted the claim from a billing entity that was different from the pre-approval. That's because the hospital uses several different business entities for filing claims. Each entity has a different account number with the payor. Yet, there is no master-sub-entity relationship for the hospital at the payor.

So, the insurance company requested that the hospital resubmit the claim. This time with the updated business entity along with my medical records.

But the hospital would only “mail’ the records. They claimed they could not fax (policy-related). They also said they had no means of sending them electronically. It would take the hospital at least two weeks to process the request. And the insurance company stated that it can take up to 30 days to review the records, once received. This is a 30 to 45-day cycle with no updates or notifications to the patient.

After 7 attempts over a 9-month period, the medical records finally arrived (at least according to the insurance company).

Oops - There Are More Issues

About 6 months into the process, a supervisor at the insurance provider also noted an issue with the date of service. It was 12 days after the pre-approval period. Now, both the date of service and the provider entity needed to change.

Sixty days later, another supervisor at the payor suggested something completely different. The hospital only needed to call the insurance provider to request a change to the pre-approval. The hospital was to call “medical management” at the insurance company and request a change of the original date and provider entity.

So, I called the hospital, provided them the pre-approval number, the persons I spoke to and the instructions.

However, the hospital said they could not do this. They had received new, contradictory instructions from the payor. The insurance company, upon finally receiving the medical records, identified yet another problem. The original claim (and pre-approval) codes were not correct. So, now the hospital needed to re-submit a newly coded claim along with another set of medical records as well as the provider entity and date changes.

More than a year into this abyss, there was no clear path to resolution.

Then One Day They Just Paid The Claim

After my last call with the hospital, I sent a summary of the above to the payor. A few days later, an alert from the payor was in my inbox. They paid the claim.

While I am still working through a few loose ends, this ordeal is finally ending.

There Is Some Good News

While the challenges I uncovered are significant, good things are happening to address some of them.

As of January 1st, The Centers for Medicare and Medicaid Services (CMS) requires digital sharing of patient records between providers. The incentives for “Promoting Interoperability” are significant. Non-compliance penalties can be more than 2% of total payments.

Additionally, companies such as careMESH are simplifying the exchange of digital medical records. careMESH digitally connects healthcare providers, large and small, as well as payors. It does this independent of the electronic hospital record (EHR). And, it ensures secure, HIPAA-compliant communications. careMESH makes exchanging health information as simple as sending an email.

But More Needs To Be Done

The excitement over new digital health technologies is out of proportion to the outcomes delivered. Accessing personal health records from an Apple device and using blockchain for smart insurance contracts are cool. But they do not address the underlying systemic issues.

The cost inefficiencies that we as patients (and the public through our taxes) end up absorbing are increasingly burdensome.

First, the patient cannot and should not be the communications network for the provider and payor ecosystem. There is too much paper and antiquated technology for patients to effectively manage. The CMS incentives and digitization of medical records by companies such as careMESH are a good start but only the beginning.

Second, providers and payors should have first line responsibility for managing their relationships. The current process puts undue financial risk on the person least capable of keeping all the information coordinated.

Providers should ensure a single digital identity of each patient. This identity should follow the patient throughout their journey.

Also, referral approvals, claims and medical records should be digital. Management of this process should fall to the payer and provider.

Third, payors should establish more transparency to accommodate their complex health plans. Without an advanced public health degree, the intricacies of these plans (much like our tax code) are incomprehensible. Even insurance provider customer service representatives struggle to find adequate resolutions when issues arise.

Finally, outcomes and financial incentives must be re-aligned. The current penalties and incentives are not compelling enough to catalyze change from the status quo. Fiscal pressures prevent most hospital systems and healthcare providers from investing in technology with the hope of future benefit. But the opposite should be true. Placing more financial and process oversight risk onto payers and providers will drive them toward a more effective process. Only when the entire ecosystem is aligned will real change begin.