Updated: Apr 26, 2020
There's an endless supply of challenges in healthcare, but is there a better way of life?
I'm Not Alone… I've Seen Healthcare at Its Best… and Its Worst.
Anyone who has worked in healthcare for a few months can describe loosely the challenges in healthcare. Heck, anyone who has access to a newspaper or the internet newsfeed can claim an awareness. For those of us who have spent and continue to invest our time and energy to this industry, we have countless stories and examples of the many great things that are possible with healthcare despite the endless list of challenges that somehow still exist.
Having held positions in two nationally recognized #healthcare systems at the administrator and director levels, I have had the great fortune of contributing to the success these organizations have created for so many patients in need of great healthcare. I have also worked alongside so many talented folks that devote their career to making a broken system work to deliver that care so desperately needed. I've heard it takes a special person to want to work in healthcare, I believe this more and more as the years pass by.
As a Director of Patient Accounting having been responsible for the accounts receivable for close to 100 clinical departments in nearly every clinical specialty, and before that an administrator responsible for helping build an organization integrating multiple private physician practices into a large academic health system I've been fortunate to be involved with the full spectrum of the #RevenueCycle as well as building financial pro formas and managing the annual performance of several practices at the same time. In addition to these two perspectives I have been a consultant to several health systems in between. I have gathered a long list of observations, pain points, frustrations, and disbeliefs. I have chosen to put this energy to good use and am determined to find ways to improve the situation. Early on I determined there are perhaps a simplified list of three issues in healthcare, what I like to refer to as the "Three T's".
Healthcare is the Greatest Industry… Despite Three Issues… The "Three T's"
For any of us who have touched healthcare, that means all of us, I believe we can all agree there are perhaps three primary issues with this industry, "Three T's":
As a patient, if you have not experienced these three issues together in one experience or even one at a time, consider yourself VERY lucky. As a professional in the industry striving to eliminate these three imposing forces is what brings me to work each day despite the temptation to walk away forever each evening as I leave the office in continual disbelief. Delivering the best possible care to a patient is what brings most healthcare professionals to work each day. For those working in areas of the industry that are not directly interacting with patients, I would suspect either the mission or something else brings them to work each day alternatively. Working to push past these three issues to create a better process is what motivates me. This wasn't always the case. I was at times tempted often to seek an easier industry. But I kept going and worked past these imposing forces over time. Here are examples of each of the Three T's depicted by real-life situations I have witnessed first-hand. As they say, the struggle is real, and for those further removed from the inner-workings of healthcare perhaps these three quick examples will be enlightening.
The First of the Three T's: Trust Breakdowns
Many features of healthcare come down to #trust. In the role, I mentioned helping integrate private physician practices into a large academic health system, I had many privileges, in particular completing by hand close to 200 Centers for Medicaid & Medicare Services (CMS) "855" enrollment forms. These forms at the time were completed on paper, signed by the clinical provider, and submitted by mail along with various supporting documents as required. The manual and time consuming process is rooted with an important tenet, ensuring the properly qualified clinician is also authorized to conduct the services required for ourselves or our loved ones. This process comes at a cost, a delay of processed payments of about 120 to 150 days by government or commercial payors on average when a provider transitions from one practice to another.
That basic purpose of credentialing and enrollment is hard to argue with. However, I have a sister who as a Nurse Practitioner licensed and certified in many ways, including the Drug Enforcement Agency (DEA) to prescribe and manage medications who experienced the extreme of this enrollment process. She chronicled her process of moving from one state to another and transferring all of her credentials in order to continue seeing patients in the career she loves. It turns out it was approximately nine months of time where she was unable to perform her services essentially having a highly qualified and well educated clinical provider unable to do what she was trained to do… or at a minimum forego compensation for her work performed for her patients.
I'm all for proving that someone is qualified to perform in their role, especially when it is dealing with clinical care. However, it is hard to accept a multi-month process to enroll a provider or at a minimum ensure that the processes between healthcare providers and payors are established properly to ensure effective performance of clinical service while striving for efficient transfer of claims in return for remittances for payment. The primary issue here comes down to trust. Trust may always be a focal point, but I would suggest new ways of doing business when credentialing and enrolling providers.
The Second of the Three T's: Transactional Inaccuracies
Am I the only one, as a patient, to have felt the joy of receiving a check in the mail from a nation-wide health insurance payor in the amount of $2,900.00 as a "confirmed overpayment" only to experience the sadness of receiving a letter from that same insurance company a month later requesting the money back? Thankfully my experience managing accounts receivable for several healthcare organizations taught me a lesson that I shouldn't be so joyful… or saddened… by transactions like this. The general process to be seen as a patient, have the claim processed for payment by the insurance payor all while I may be seen at another provider is complicated and takes time. The time between makes it difficult for databases to be kept up with timely and to have the latest information or the full picture. This transactional #inaccuracy is likely experienced every time one receives an explanation of benefits (EOB).
This is just one example and each of us probably experience this every month if we have an active life in healthcare providers' offices. In fact, some of us may have figured out to wait a billing cycle… or two… before paying a claim just to be sure that all the information has caught up on each of the systems involved from the provider to the clearinghouses and to the payor. The process of processing claims creates transactional inaccuracies that is a second critical issue in healthcare.
The Third of the Three T's: Throughput Inefficiencies
Even when the transactions may be processed correctly, the process of routing claims from a provider to a payor and payments from the payor to the provider is fraught with #inefficiency. While responsible for the accounts receivable as well as the processing of payments from government and commercial payors to resolve the outstanding accounts receivable, I've waited by the phone and email on the Wednesday before a Thanksgiving, the Friday after, and even that Saturday also as we searched with our clearinghouse business partner for a missing $1M electronic remittance.
This Thanksgiving in particular happened to fall on the last couple business days of that month. The fiscal month-end process in every healthcare organization is an arduous one. Having a $1M discrepancy to have to explain in addition is a painful proposition. To explain a bit further while sparing some accounting details the $1M check from the payor was fortunately deposited in the bank of the provider. However, the electronic remittance advice (ERA) which provides the details of what claims the payor is processing and how the payor is directing all of the related payments, adjustments, and denials to be processed against the accounts receivable is what was missing over that Thanksgiving weekend. We found out that next Monday, now December and too late for the $1M payment to help reduce the accounts receivable balance, that the clearinghouse had simply moved the ERA file to the wrong system folder. If it was only that simple to explain how it could have happened so easily to begin with. The throughput inefficiencies are astounding to say the least.
How can an industry every single one of us depends on so much, be so broken? How can so many people receive such incredible care, improvement, and even miracles despite the amount of work, bureaucracy, and inefficiency involved to make that possible. Maybe that is part of the miracle too, that people come to work each day knowing they have patients to care for, are doing so while facing an industry that is broken, and somehow make it work every day, albeit some days better than others.
So, What Do We Do About This Dilemma?
As a result of experiencing any one of these three trials and tribulations I like to refer to as the Three T's, I could go home every night and decide abandon the industry I have invested so much of my time and effort. Or I could let it ruin most evenings by letting the emotional frustration get the best of me. Or better yet, I could take inventory of these challenges, and many others, and use them as lessons and insights as to what is broken about the industry I love and pursue case studies to see if there are better approaches to solve some of these problems.
No one wants to hear complaining. What we all want, and especially those further removed from the administrative chaos of healthcare especially patients and their families, is to hear that folks are working hard and thoughtfully to improve the processes of this broken industry.
As you will see in later posts, this inventory of issues coupled with a conversion of frustration to problem-solving happened around a particularly lucky day that revealed a beacon of hope. This website is an effort to examine some of the challenges in healthcare, explore how emerging technologies, in particular #DistributedLedger (#DLT)(#Blockchain) as well as #ArtificialIntelligence (#AI) may help solve some of these problems for the long haul.
I hope you will continue the conversation in the GAME CHAiNGER Forum, or simply our mailing list to be updated as soon as information is published. But most of all, I also hope you are like me, motivated to see a better way of life for all involved with healthcare because we need a game changer… desperately.
Thank you for reading this post.