By MARGALIT GUR-ARIE
2010 is drawing to an end amongst a flurry of activities in the Health IT field. In a few short days 2011, the year of the Meaningful Use, will be upon us and the stimulus clocks will start ticking furiously. In addition to the yearlong visionary activities from ONC, December 2010 brought us two landmark opinions on the future of medical informatics. The first report, from the President’s Council of Advisors on Science and Technology (PCAST), recommended the creation of a brand new extensible universal health language, along with accelerated and increased government spending on Health IT. Exact dollar amounts were not specified.
The second report from the Institute of Medicine (IOM) is a preliminary summary of a three-part workshop conducted by the Roundtable on Value & Science-Driven Health Care with support from ONC, and titled “Digital Infrastructure for the Learning Health System: The Foundation for Continuous Improvement in Health and Health Care”. The IOM report, which incorporates the PCAST recommendations by reference, is breath taking in its vision of an Ultra-Large-System (ULS) consisting of a smart health grid spanning the globe, collecting and exchanging clinical (and non-clinical) data in real-time. Similar to PCAST, the IOM report focuses on the massive research opportunities inherent in such global infrastructure, and like the PCAST report, the IOM summary makes no attempt to estimate costs.
Make no mistake, the IOM vision of a Global Health Grid is equal in magnitude to John Kennedy’s quest for“landing a man on the moon and returning him safely to the earth” and may prove to be infinitely more beneficial to humanity than the Apollo missions were. However, right now, Houston, we’ve had a problem here:
- The nation spent upwards of $2.5 trillion on medical services this year
- Over 58 million Americans are poor enough to qualify for Medicaid
- Over 46 million Americans are old enough to qualify for Medicare
- Another 50 million residents are without any health insurance
- The unemployment rate is at 9.8% with an additional 7.2% underemployed
- This year’s federal deficit is over $1.3 trillion and the national debt is at $13.9 trillion
In all fairness, the recent Federal investments in Health IT were spurred by the HITECH Act, which was a part of the ARRA, a recession stimulus bill aimed at injecting money into an ailing economy and creating jobs, while improving national infrastructure. It was not explicitly intended to reduce health care costs or improve access and affordability (that came later with PPACA). Perhaps adding an EHR to every doctor’s office was viewed as the first step towards building the Learning Health System. However, somewhere along the road to fame EHRs were magically endowed with powers to provide patients “with improved quality and safety, more efficient care and better outcomes”. Perhaps these claims came from EHR vendors’ glossy marketing collateral, or perhaps it was just wishful thinking, or perhaps this was a forward looking statement for the fully operational grid of a Learning Health System, or maybe this is just incorrect use of terminology. Health IT is much more than EHRs and Health IT can indeed help improve efficiency, i.e. cut costs, in several ways.
Administrative Simplifications
Section 1104 of the PPACA contains a roadmap for administrative simplifications “to reduce the clerical burden on patients, health care providers, and health plans”. Eligibility transactions must be standardized and deployed by 2012, electronic payments by 2014 and claims, certifications and authorizations by 2016. Physicians spend about 14% of revenue on billing and insurance related functions, while hospitals spend 7% – 11% and health plans spend around 8%, not to mention the aggravation involved. Why do we have to wait 6 years before this particularly wasteful activity is completely addressed? If there is a place where health care can learn from other industries, this is the one. Both the banking and retail industries have solved this problem many years ago. It is trivial to imagine swiping a magnetic card at the doctor’s office to verify eligibility, obtain authorization, and exact dollar amounts for patient responsibility, while initiating a real time payment transaction from insurer to provider. The complexities of a thousand different plans can be easily accommodated by computer algorithms and the technology is available in every supermarket and every gas station. For all those joining Congress in 2011 with the intent of altering PPACA, could we alter Section 1104 and shorten the timeline by a few years?
Fraud
The National Health Care Anti-Fraud Association estimates the costs of health care fraud to be 3% to 10% of expenditures. Despite all the publicity, credit card fraud is estimated to cost 7 cents per each $100 in transactions, or 0.07%, with issue resolution times estimated at 21 hours. This is yet another lesson health care can learn from the financial industry. Granted, purchase patterns in health care are different than the market at large, so the anti-fraud algorithms will need to be tweaked and specialized. Computers are very good at this and from watching the President’s bi-partisan meeting on health care reform last year, I thought this is one area where everybody agrees that something needs to be done. There is nothing tangible in PPACA regarding the use of Health IT for fraud reduction.
Duplication of Tests
If you prescribe electronically through Surescripts, you can see a patient’s medications list courtesy of the PBM. PBMs and insurers know exactly what medications they paid for. They also know exactly what procedures, tests and visits they paid for, and who performed them. Would it be a huge stretch of imagination to envision a display of the last 6 months of tests paid by the insurer every time you attempt to order a test? No, insurers don’t have the results, but if you saw that the patient had an MRI last week, would you order another one today? Or would you call the facility for a copy? When you prescribe electronically, the PBM insists on showing you the formulary and drug price for the individual patient. Why not show you prices for the tests you are about to order, and help you and the patient choose lower priced facilities, just like they steer folks to prescribe generics? This has nothing to do with clinical decision support or changing the way medicine is practiced. These are examples of very simple, common-sense, immediate solutions for reigning in costs without disturbing quality of care.
The Global Learning Health System presents a compelling vision. I wish that the President would commission the necessary budget estimations, go before Congress and in a JFK style oration request appropriations for defeating Cancer (or some other scary thing), appropriations which will include funding for the Learning Health System global grid. It is possible that if such Learning Health System existed today, or could be quickly deployed, it would provide solutions for most health care problems we currently have. However, it is pretty clear that such a system will take many years and many billions of dollars to build. In the meantime we have an immediate problem, which requires an immediate solution with immediately available tools, and no, failure is still not an option.
Margalit Gur-Arie blogs frequently at her website, On Healthcare Technology. She was COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization.
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Those born poor are neither lazier nor dumber than those born rich. They are just less lucky….
you don’t measure at birth margalit you measure when they reach death or the end of their productive years. The stats I posted show termendous movement from poverty up 1 or 2 quintiles. Those with inteligence and work ethic don’t stay poor.
Those in their 30s-60s that are poor are less productive, lazier then those that have more wealth
Thank you Dr. Walker. I too hope that sanity will somehow prevail.
Margalit, superb post with analysis that, in itself, is so logically sound and airtight that it renders hope that we might just get through this healthcare maze after all. Keep it flowing…
As a descendant of a dirt-poor illegal who invaded this continent when it was under a previous regime 375 years ago, this is getting too ugly for me.
I should know better, but here it goes….
Those born poor are neither lazier nor dumber than those born rich. They are just less lucky….
This country was built on repeated invasions of dirt-poor people who over hundreds of years supplied the fodder for wealth creation… in more ways than one.
YUP
Poverty persistent in USA? Gee — that couldn’t a result of dirt-poor illegals invading the USA, could it?
Understanding the denominator is as important as understanding the numerator. Someone tell that to Robert Reich.
———-
just yahoo search quintile high earners or hours and all sorts of facts come up showing the reason for the increase in prosperity is our poor are lazy and stupid
just yahoo search quintile high earners or hours and all sorts of facts come up showing the reason for the increase in prosperity is our poor are lazy and stupid
http://www.nber.org/digest/jul06/w11895.html was the last one you mentioned
as an employer I’m always shocked at what you get for minimum wage, there are millions of people who aren’t worth $2.00 per hour let alone $7 plus depending on where you live
FACTS ARE BRUTAL
FACT: The top 25% ($68,000+) pay 87% of federal personal income taxes.
http://www.ntu.org/tax-basics/who-pays-income-taxes.html
Dang! How much more can OWEbama grab?
As for 2009 tax collections — a bunch of tax-funded Harvard buddies of OWEbama FORGOT to note that 2008 was a NEAR-DEPRESSION. Duh.
As for post-WWII prosperity — well, gee, all the USA has to do is destroy Japan and Germany again! Because the USA was prosperous while Japan and Germany rebuilt!
If someone does NOT have a background in math, statistics, economics, accounting and finance (Robert Reich) — they should stop popping-off about macro-economics.
It is just wasting everyone’s time. Thanks.
———–
“The top went from 58 to 66, so the rich have assumed more of a burden then they has before.”
Isn’t this the natural outcome of assuming a larger piece of the national wealth pie?
“spend a few nights in the the hood and tell me they are only making 16K per year”
Who is “they”?
“By contrast, adults in the top quintile work an average of 34.6 hours per week”
34.6 hours per week doesn’t strike me as “working hard”.
And how about the vast majority in between the highest and the lowest quintiles?
Where are you quoting from, Nate?
Nate: My point was that, as Frank said, percentage of taxes paid by the top quintile went up during the period studied, but income for that quintile went up much more-that is, the tax/income ratio decreased for the top quintile. Which means that, as tax burden for the total population is decreasing, it’s the middle class that’s getting the shaft.
“In 1983, the most poorly paid 20 percent of workers were more likely to put in long work hours than the top paid 20 percent. By 2002, the best-paid 20 percent were twice as likely to work long hours as the bottom 20 percent. In other words, the prosperous are more likely to be at work more than those earning little. This trend has been a puzzle for some economists.”
What crazy anti liberal talk, those actually working more earn more…something should be done to stop that, we need to tax those that do work so the people that dont work can make just as much….. right Margalit,
Wonder what happened in the 60s and 70s that allowed poor people to work less but live better….odd
what would you have expected it to go up pcp? Did you know the value of used cars deceases most years? Thats becuase they are of less value. Compare the hours worked and education level of the lowest quintile
“Between 1979 and 2002, the frequency of long work hours increased by 14.4 percentage points among the top quintile of wage earners, but fell by 6.7 percentage points in the lowest quintile.”
“Hours worked differ substantially across income levels. Adults in the lowest quintile work an average of only 14.4 hours per week, less than one-half of a typical 40 hour workweek. By contrast, adults in the top quintile work an average of 34.6 hours per week.”
And keep in mind that is reported income, spend a few nights in the the hood and tell me they are only making 16K per year.
Exactly, Ms. Gur-Arie.
In the article that Frank has so kindly referenced, we see that income for the lowest quintile has gone down 2%, while that for the top quintile has gone up 55%. And that’s only up until 1997.
“The top went from 58 to 66, so the rich have assumed more of a burden then they has before.”
Isn’t this the natural outcome of assuming a larger piece of the national wealth pie?
“Federal, state and local income taxes consumed 9.2% of all personal income in 2009, the lowest rate since 1950, the Bureau of Economic Analysis reports. That rate is far below the historic average of 12% for the last half-century. The overall tax burden hit bottom in December at 8.8.% of income before rising slightly in the first three months of 2010.”
In 1950 what percent of the population was paid by the federal government just for being a citizen? Did we have earned income tax credits for kids? income taxes have become a liberal wealth redistribution tool, of course the percentage has dropped. When almost half the population pays no income tax or gets a refund after paying no to little income tax what did you expect?
Where does your argument account for other taxes like real estate and sales tax?
When since 1950 has our unemployement been this high?
http://www.bls.gov/cps/prev_yrs.htm
well look at that, except for 1982-1983 it has never been that high. in fact it is 2-3 times higher then usual.
Wonder what would happen if employement income dropped 10-20% from unemployement and recession, and we started giving income tax refunds to people who dont pay income tax……
tax rate comparison is meaningless, if anything compare effecive tax rate paid.
http://www.cbo.gov/ftpdocs/88xx/doc8885/EffectiveTaxRates.shtml
lowest Quintile had an effective income tax rate of negative 6.5%. Oddly that wasn’t reflected in Margalits argument. According to Margalit they should be paying 10-15% but in reality they are getting back 6.5%. Thats a 16.5% to 21.5% difference. What value is it arguing or discussing rates that don’t exist?
http://www.cbo.gov/ftpdocs/30xx/doc3089/EffectiveTaxRate.pdf
page 187 is interesting, the poor went from -0.3 in 1979 to -2.1 in 2000. Your right tax burden has decreased, not sure you can really call it a burden when your being paid taxes.
The top went from 58 to 66, so the rich have assumed more of a burden then they has before.
“Because, with the amount of inflation over a century, that’s a meaningless figure.”
To bad no one has ever figured out a way to invest for inflation.
“Total of all taxes paid by all Americans divided by total of all income earned by all Americans.”
Here is the real answer, you want to cover or avoid the question of who is paying less and who is paying more. You want to partner the argument that America as a whole” pays less with the argument the rich dont pay their fair share to increase taxes only on that small class of people that don’t deserve their wealth.
If people started seeing that 45% of the population wasn’t paying federal taxes or that the rich pay the vast majority of all taxes already then people might start thinking it is distribution of taxes that are a problem and not the amount.
“Federal, state and local income taxes consumed 9.2% of all personal income in 2009, the lowest rate since 1950, the Bureau of Economic Analysis reports. That rate is far below the historic average of 12% for the last half-century. The overall tax burden hit bottom in December at 8.8.% of income before rising slightly in the first three months of 2010.”
USA Today, 5/10/2010
TRY THINKING — USUALLY DOESN’T HURT (MUCH)
“tell us where that bottomless pit of TAXES is.”
Well, as total tax burden on the American population is at the lowest level since the Truman administration, I think it’s safe to say we’re nowhere near the bottom currently.
>> Total? Total average? Total marginal? At the median? Or the mean?
>> No limits to spending — spending is LIMITLESS. And the SPEND-O-CRATS have proven that!
—-
Maybe it was the 1950s and 60s, the period of the greatest economic expansion in the history of this country, when the top rate was 88%?
>> You left out tax deductions and tax shelters. That affects the marginal rate. Duh.
—-
Here are the tax rates since 1913. Very enlightening…..
http://www.taxfoundation.org/files/fed_individual_rate_history-20101220.pdf
>> You left out tax deductions and tax shelters. That affects the marginal rate. Duh.
—
RETIRE OWE-BAMA IN 2012!!!
“Why not look at total dollars paid since 1913?”
Because, with the amount of inflation over a century, that’s a meaningless figure.
“measured how?”
Total of all taxes paid by all Americans divided by total of all income earned by all Americans.
why is rate a valid measure? Why not look at total dollars paid since 1913?
” total tax burden on the American population is at the lowest level since the Truman administration,”
measured how? As a population we are paying more taxes now then we did back in the Truman days.
Here are the tax rates since 1913. Very enlightening…..
http://www.taxfoundation.org/files/fed_individual_rate_history-20101220.pdf
“tell us where that bottomless pit of TAXES is.”
Well, as total tax burden on the American population is at the lowest level since the Truman administration, I think it’s safe to say we’re nowhere near the bottom currently.
Maybe it was the 1950s and 60s, the period of the greatest economic expansion in the history of this country, when the top rate was 88%?
TRY REALITY
OWEbama has NEVER held a front-line, get-your-hands-dirty job.
Anyone who has seen, first-hand, I.T. installs knows that OWEbama and his dubious band of naive Utopians have proposed something with only an iota of attachment to REALITY.
The USA is not Switzerland or Japan — there are NO Afro-Japanese or Latino-Japanese in Japan.
Making big changes in I.T. has a FIFTY PERCENT failure rate, even with HP in charge. Very, very hard work.
And someone tell Welfare Queen Pelosi, tell us where that bottomless pit of TAXES is.
Repeal. Repair. And for God’s sake, put adults in charge.
processing claims is a generic term.
Medicare Payors process claims, have a 10% fraud rate and even worse error rate. The pay them quick but no right and waste a fortune.
BUCA processes claims, very automated but again with lots of errors and not a very good job controlling cost.
Then there are people like me doing it the old school way, actually having humans look at the claims, lower error rates, lowest fraud, and lowest total cost.
People tried the automated lets treat claims like financial transactions and their cost went through the roof. They are going back the other way and looking for people to actually process claims like the 2.5 trillion expense they are; not gas station credit card swipes.
Technically I make my living managing plans, part of which is processing claims. If it was in the best interest of my clients to auto adjudicate medical claims I would, it would save me a ton of money. Already have the system and everything to do it, just because I can do it and its in my best interest doesn’t mean its the right thing for clients.
I’m sorry, Nate. It just dawned on me that you make a living processing claims. I know you do more than that, so perhaps if computers take over actual processing, you could concentrated on those value added services I’m sure you also provide.
Is there more then one Margalit?
” the algorithms are so sophisticated now that it is practically impossible to use a credit card fraudulently more than once or twice.”
” two $1 charges to some internet stores and one $50 charge from iTunes.”
Sounds like three to me. Are all your arguments so mallable? Or did the practically impossible just happen to happen?
Seems your sophisticated algoritms aren’t so sophisticated after all.
“Why does a provider have to send the patient name, address, date of birth, marital status, etc. every single time?”
Are you proposing an 837 format for the first time a claim is sent then a 838 for subsiquent claims, cause that makes perfect sense. How exactly do you expect claims to be identified? Would you like to send out millions of dollars based on a single data point? Again brilliant.
“Why is the provider address required every single time?”
How would we know if it changes if it isn’t sent every time? And again you want to send millions based on a single NPI? Sure how data doesn’t get out of alignment in Margalit’s world of no redundency and verification. We usually require 2 of 3 or 3 of 4 data points match before we allow a claim to proceed, hey what do we know only having done this for decades.
Your EDI numbers are overstated, that is AHIP members who tend to be large insurers with their own network, EDI is lower in the self funded market and B carriers.
“There is no way a “dead” provider number could bill Medicare for many millions over years and years.”
Do a google search for deceased credit card and tell me again how great your algorithms are.
If we really want to look at a comparison industry for complex data management and evaluation, take the gambling and security technology from the gaming industry. The combination of ‘player’s card’ use, charging activity, facial recognition, spending and travel patterns are coalesced with the ‘simple’ goal of minimizing loss.
The building blocks are available, there needs to be the financial backing and cooperation.
Simply starting with demographic data including allergies and major medical conditions on ‘smart’ card would bring us a long way from where we are now (ie Taiwan, France etc).
Good luck implementing with current political disarray/special interests.
Connie, just to be clear, JFK’s name is associated here with curing Cancer and a global learning and research network to benefit all people on this planet in the fight against epidemics, disease, suffering and hopefully poverty itself.
A far cry from CPOE.
Nate, an 837 is nothing more than an EDI format of the CMS 1500. All the data elements in CMS1500 need to be in an 837. Why does a provider have to send the patient name, address, date of birth, marital status, etc. every single time? Why is the provider address required every single time? Would you accept such antiquated bureaucracy when paying for steak? How many claims are rejected for demographics errors because the name on the card doesn’t match the claim (Jon instead of Jonathan)?
Most providers make photocopies of perfectly good insurance cards and then type in the details. How does that make any sense nowadays?
As to EDI, 82% of claims are submitted electronically and 75% are adjudicated electronically, so why not take the next step and make it all electronic?
http://www.ahipresearch.org/pdfs/SurveyHealthCareJan252010.pdf
It’s almost funny how everybody seems to think that computers will bankrupt their profession, not just doctors. In your case, managing payment for services, computers have not bankrupted anyone yet. Quite the opposite.
The other day I got a call from one of my credit cards automated fraud service checking potentially fraudulent activity: two $1 charges to some internet stores and one $50 charge from iTunes. That’s what they called me for and they were correct, it wasn’t me. They canceled my card and sent a new one before any serious damage occurred (all automated). Those petty charges didn’t match my profile. Algorithms are like magic. They work really well. There is no way a “dead” provider number could bill Medicare for many millions over years and years.
“many of the required data elements are superfluous. ”
Care to give any examples? Just becuase you don’t understand their use doesn’t mean they are superfluous.
“I don’t see why prompt payment means that you will be robbed anymore than VISA and MC are getting robbed. You do have rules right now on what you are obligated to pay for, so applying them and running utilization algorithms continuously should give you pretty solid protection,”
Some study in computer fraud would clear this up for you pretty easy. A coded system is close to worthless once the code is known. Once you figure out the algorithms it is worse then there being no algorithms. Those systems are built with a flaw, they trust the algorithms to keep out what is not suppose to be there, once your behind the wall its a financial buffet to gourge yourself sick. This is one reason Medicare fraud is so bad, once people crack the sytsem the system helps them steal more then if there was no system.
If we can’t even get doctors to use EDI today, a very small first step compared to what you propose how do you think your giant leap will succeed?
As a family doctor, census in hospital averages 13, my family practice went to a family circus once the hospital ill advisedly deployed CPOE. No one has time to communicate. The computer electronics is a new disease, sapping time.
Although he failed at the Bay of Pigs, it is a dishonor to JFK that you associate his vision of space with meaningfully useless and time consuming CPOE. His intellect would have seen through the fraud on America.
Dr. Stenes,
I think you are misunderstanding my argument.
I don’t think IOM is smoking anything (it would be politically incorrect :-)).
I do however think that the vast research network that IOM is envisioning, while no doubt a very useful thing to have, is an enormous undertaking that needs to have some explicit goals attached to it. Improving quality of care is, frankly, not something I can get my arms around and sounds too generic and devoid of any measurable meaning.
I am not advocating for CPOE, here or elsewhere. CPOE notwithstanding, would you be interested in seeing a recent list of orders before you order something? Not being the patient’s financial adviser notwithstanding, would it help if test prices for the patient would show up somewhere for both of you to see?
I do believe that a small set of pertinent information, readily exchangeable would represent a positive contribution to that elusive “quality of care” goal. However, I believe we are concentrating on the most complex and debatable part of the problem (i.e. the clinical portion), instead of the much simpler and less controversial issue of exchanging fees for services, which carries the most potential for cost containment.
If you have the time and interest, here is a more explicit version of my opinion on this unnecessarily complex state of affairs:
http://onhealthtech.blogspot.com/2010/12/health-it-and-carob-tree.html
Nate, I know exactly what an 837 looks like and many of the required data elements are superfluous.
There is a level of complexity in medical billing that is unexplainable. It needs to go away. The transaction itself is rather simple, from an arithmetic point of view and not too complex from a rules engine point of view.
There should be no need to type in a POS device anymore than there is a need to type at a supermarket checkout. This things should be wired into existing practice management and EMR systems.
You are correct, the technology is there and some payers are trying it out, but there are too many other considerations that are getting in the way.
I don’t see why prompt payment means that you will be robbed anymore than VISA and MC are getting robbed. You do have rules right now on what you are obligated to pay for, so applying them and running utilization algorithms continuously should give you pretty solid protection, along with good authentication and authorization mechanisms.
The computerization of medicine has paradoxically debilitated it.
The IOM is smoking weed.
Margalit, when was the last time you managed a patient with respiratory failure, renal failure, heart failure, anemia, diarrhea, and gastrointestinal bleeding? Better yet, did you need to treat the associated CPOE disease interfering with timely and efficient care?
The problems are basic and not solvable with high falutin meaningfully useless CPOE gear…like stupid and poorly trained staff with low morale (because the CEO make a few mill $ and fires innumerable kew employees), like tests that do not get done, like patients that are ignored (sorse with EHRs), like guidelines that promote errors…how many do you want to read?
Have you seen the layout of a credit card transaction? Or a more common one, that people can see not volumn, would be a NOCHA or ACH file. Compare that to the size of an 837.
FYI VISA can’t tell you the product purchased, it doesn’t capture that much data. Terms and conditions aren’t part of the transaction either and currency conversion isn’t anything hard. If you want a more accurate comparison look at court records for example, how has that automation gone? Property Records would be a more accurate comparison, again hasn’t automated very well.
There are already real time payment products on the market, its not a question of the technology but being a terrible stupid idea unless your looking to get robbed. Its being done now in exchange for deeper discounts, payors will pay real time or 48 hours in exchange for paying Medicare or Medicare plus 10% for example.
What do we do for all the people that don’t have credit cards?
VISA and MC charge 1-3%, are providers going to want to give that away? An ACH is free to .10, that is a considerable difference in income. What does a doc collect per year? 1-2 million? 30K to 60K a year to take a credit card, doesn’t sound very efficient.
We have a system where a provider can sign up on a website to receive their EOB and payment electronically. Once they sign up when we go to print a check for them it redirects it into an ACH and deposits right into their bank, usually cost them nothing. Considerably cheaper then running credit cards.
Who at the providers office is going to do all this typing into the POC? POS? machines?
Hello Nate. I must confess that when I chose the word “residents”, I was thinking about you. We do have different opinions regarding the validity of concerns for the welfare of those without legal status in this country.
As to the magnitude of transactions and general ability of computers do deal with volume, VISA, for example, is accepted at 24 million locations world wide, each with a large set of products, many different currencies, various local regulations, multiple terms & conditions, etc. Yet, computers deal with all this complexity elegantly and efficiently. Number of computations is largely irrelevant to complexity and so are deterministic decision trees.
Computers are really and truly great at this stuff, Nate. Dealing with ambiguity, like you find in clinical decision making, is what brings computers to their knees.
I did not expect insurers to embrace the prospect of real time payments to providers, but here is one way it could work:
1) Card is swiped at check-in – Eligibility for coverage is determined. Pre-adjudication for whatever is planned for today can be performed at the same time.
2)Services performed
3) Card swiped at check-out, after ICD and CPT are entered (like scanning tuna cans at supermarket). Full adjudication, including medical necessity, and final amount payable to provider determined and subtracted from total allowable = patient responsibility.
4) Patient pays by credit card (until some smart insurer collaborates with VISA or MC to have 2 in 1 cards tied to HSA account).
5) Insurer initiates transfer of funds to provider’s merchant account.
One little POC machine at every provider location and all the improperly filled out claims problems will be just a bad memory…..
As to fraud, yes some of it is retroactive, but the algorithms are so sophisticated now that it is practically impossible to use a credit card fraudulently more than once or twice. Contrast this with the horror stories of Medicare being ripped off by folks over years of strange activities and you come out ahead significantly.
“but a human must first identify the problem then program for it” – Exactly. And the financial industry is doing a fantastic job at this.
I trust payers are equally well positioned to run algorithms, since they already are doing so, but for very different reasons.
Thanks, Margalit for another insightful and informative post. You make very good points. I also cannot understand why these simple measures have not been implemented for duplicate tests, fraud, and standard transactions where other industries have solved these problems long ago.
Nate, I was going to try to respond to your points but you are making even less sense than usual.
4.Another 50 million residents are without any health insurance
residents is an interesting choice of words. If you got rid of the 10+ million illegal “residents” wouldn’t that have a pretty big impact on the 2.5 trillion we spent? And also have a big effect on the deficit?
“Both the banking and retail industries have solved this problem many years ago.”
They are able to do this becuase the person inititating the tranaction has a financial interest in it being legit. When a patient sees a doctor they are spending someone else’s money, much harder to keep things honest when the person isn’t there. How many parents would give their kids an Amex and expect nothing bad to come of it?
” It is trivial to imagine swiping a magnetic card at the doctor’s office to verify eligibility, obtain authorization, and exact dollar amounts for patient responsibility, while initiating a real time payment transaction from insurer to provider.”
Trivial? How many of these have you done?
How does the magnetic card know the employee just quit his job after stealing money?
How does the magnetic card know to x-rays to determine if a procedure is warranted?
How does a magnetic card know what the patient responsibility is if the primary payor of the bill hasn’t determined what their liability is?
You have heard of fraud as you mention in the next paragraph, how does an insurer prevent fraud when a provider can electronically withdraw funds directly from them on demand?
I always find it humerous that people that have never engaged in an activity or process can trivilaize it so easy. Thats is what creates disasters when politicians or liberals that have no idea what they are talking about say oh this is easy here its now law. See Medicare requirement to pay providers in 30 days, how has that worked out?
” It is trivial to imagine swiping a magnetic card at the doctor’s office to verify eligibility, obtain authorization, and exact dollar amounts for patient responsibility, while initiating a real time payment transaction from insurer to provider.”
Margalit you suck at math. A grocery store carries roughly 45,000 items. Period that is it, not even a very large data base. Currently there are 10K CPT codes, going up to 40K I think? 1500 diagnosis codes or so. Couple million providers. and roughly 300,000,000 patients. My calculator doesn’t have that many spaces. I count roughly 18 0’s in the number though
45,000
1,000,000,000,000,000,000
Let me guess trival?
“Computers are very good at this”
Actually no Margalit computers are terrible at this, that is why Medicare has a 10% fraud rate. First off computers are only good at mining data or searching for a pattern. Both of those require fraud already have happened and been identified. If I know a provider is suspect a computer is great and digging through billions of bytes to find similar situtions. Under your suggestions these bills would have all already been paid and you would be chasing criminals for money back. Computers are good for finding patterns, you can program a computer to look for a provider that does X then Y and alert you so the claim isn’t paid, but a human must first identify the problem then program for it.
Thanks, pcp. I agree EHR agree not very likely to change one’s behavior, for better or for worse.
Thanks Lisa. I left errors out because everything I read tells me that while some errors may be prevented by an EHR, other, newer errors may be introduced.
Interestingly enough, Millman conducted a study on hospital injuries, which they termed “errors”, but most docs would refer to those as “complications”. Either way, many are avoidable (at least in some part), and the most prevalent and most expensive are bed sores and infections. Bed sores and infections.
http://www.healthleadersmedia.com/page-2/QUA-254873/Top-10-Most-Costly-Frequent-Medical-Errors##
I think much lower tech tools are needed to prevent those injuries.
Excellent article. I think you missed another big cost saving opportunity for HIT, though, which is avoiding medical errors through identifying omissions and commissions of error. This can be done on both an inpatient basis (e.g., detect wrong dose of medication at the bedside thus avoiding potentially costly treatment to ameliorate the result of the mistake) or outpatient basis (algorithms that detect, for instance, contraindicated meds given by two different unaware physicians). Medical errors account for billions of dollars in cost to the healthcare system and avoiding them is as good as it gets to combining cost savings opportunities with improved patient care.
Another great post. Thanks.
“if you saw that the patient had an MRI last week, would you order another one today? Or would you call the facility for a copy?”
If you practice good medicine, you’ll do exactly as you do now (when the patient or referring doc says that an MRI was already done) and call. We already have GREAT ways to communicate, and adding another won’t do away with laziness.
Or, if you own your own magnet, you’ll do exactly as you do now and order another scan.
EMRs don’t have some magical ability to change behaviour.