Make ad­min­is­tra­tive sim­pli­fi­ca­tion the first step on path to com­pre­hen­sive health re­form

Modern Healthcare - - COMMENT - By Dr. Matthew Hahn

Repub­li­can ef­forts to re­peal and re­place the Af­ford­able Care Act are in dis­ar­ray. And the re­al­ity is that no com­pre­hen­sive ap­proach to health­care re­form has the sup­port needed to pass in this deeply di­vided Congress. So the search has turned to “skinny” or more-lim­ited so­lu­tions.

Des­per­ately needed ad­min­is­tra­tive sim­pli­fi­ca­tion of the rule-bound U.S. health­care sys­tem would be the per­fect so­lu­tion. It could give an im­por­tant shot in the arm to Amer­i­can medicine and pro­vide an easy po­lit­i­cal win for the be­lea­guered Congress.

Health­care ac­counts for al­most 18% of the na­tion’s gross do­mes­tic prod­uct, and, by some es­ti­mates, 30 cents of ev­ery health­care dol­lar goes to ad­min­is­tra­tive costs, dou­ble the amount spent by most other na­tions. Elim­i­nat­ing ad­min­is­tra­tive waste rep­re­sents the most ob­vi­ous and im­me­di­ate op­por­tu­nity to lower un­nec­es­sary health­care spend­ing, the Achilles’ heel of our med­i­cal sys­tem.

To­day doc­tors and other clin­i­cians in the U.S. fight less against dis­ease and more against a mas­sive sea of red tape. Get­ting care of­ten de­pends not on a clin­i­cian’s skills but on their knowl­edge of (and the time for) the work­arounds made nec­es­sary by our byzan­tine sys­tem.

Get­ting paid for a sim­ple of­fice visit to­day is more com­pli­cated than the visit it­self. Fed­eral reg­u­la­tions dic­tate that just to cal­cu­late the amount a doc­tor can charge for an ap­point­ment, he or she must use a bizarrely com­pli­cated for­mula, count­ing the num­ber of body parts dis­cussed with a pa­tient, the num­ber of body parts ex­am­ined, and es­ti­mat­ing the com­plex­ity of their med­i­cal de­ci­sion­mak­ing. This “eval­u­a­tion and man­age­ment” (E/M) cod­ing sys­tem is overkill on the level of what we did to the buf­falo in the 1800s.

A claim for a typ­i­cal Medi­care pa­tient’s of­fice visit (which pays an av- er­age of $75) can go to a half-dozen places—ad­dress­ing de­ductibles, co­pays, pri­mary in­sur­ers and sec­ondary in­sur­ers—be­fore it is fi­nally paid or, just as eas­ily, re­jected. Each step is an op­por­tu­nity for an er­ror, a dis­crep­ancy or a de­nial, all of which are com­mon. The sys­tem cre­ates waste on a mas­sive scale and in­vites fraud.

Get­ting pre­scrip­tions and sim­ple tests for pa­tients can take hours of work be­cause of in­sur­ers’ prior au­tho­riza­tion re­quire­ments. One re­cent Fri­day even­ing I re­ceived an af­ter-hours phone mes­sage from a pa­tient with Type 1 di­a­betes who was run­ning out of in­sulin. The pre­scrip­tion was held up in prior au­tho­riza­tion. The pa­tient had been on the same in­sulin for years and needs it to sur­vive. In all, it took ap­prox­i­mately a week to get the med­i­ca­tion ap­proved. This need­lessly com­pli­cates treat­ment and en­dan­gers lives.

Here is the fix: All new CMS ad­min­is­tra­tive pro­grams should be put on hold un­til true ad­min­is­tra­tive sim­pli­fi­ca­tion takes place. They must wipe the slate clean to cut un­nec­es­sary spend­ing so health­care pro­fes­sion­als can fo­cus on pro­vid­ing and im­prov­ing pa­tient care.

To be­gin, all as­pects of get­ting paid for med­i­cal care should be dra­mat­i­cally sim­pli­fied. The E/M cod­ing sys­tem men­tioned above must be over­hauled. Most med­i­cal billing for sim­ple of­fice ser­vices and pro­ce­dures should be elim­i­nated en­tirely in fa­vor of pointof-care pay­ment strate­gies, such as health­care pay­ment cards (a debit card per­haps) for all types of pay­ers. Prior au­tho­riza­tion pro­cesses should be re­served only for ex­tra­or­di­nary tests and treat­ments. Even then, they need to be stream­lined and straight­for­ward.

There are plenty of other po­ten­tial ar­eas for ad­min­is­tra­tive sim­pli­fi­ca­tion, in­clud­ing a uni­ver­sal web­site where all pa­tient and provider in­sur­ance in­for­ma­tion, and pro­fes­sional li­censes, cer­ti­fi­ca­tions and cre­den­tials are main­tained and can be se­curely ac­cessed. A uni­fied set of rules and forms should be es­tab­lished re­gard­ing all such things. And the no­to­ri­ously com­plex HIPAA pri­vacy and se­cu­rity rules would be far more ef­fec­tive if they were far sim­pler.

Mean­while, the Medi­care Ac­cess and CHIP Reau­tho­riza­tion Act, the govern­ment’s new “value-based pay­ment” sys­tem, makes no sense in the cur­rent en­vi­ron­ment, be­cause it ac­tively pre­vents value on mul­ti­ple fronts.

These types of im­prove­ments can be in­cre­men­tal, but ad­min­is­tra­tive sim­pli­fi­ca­tion rep­re­sents an im­por­tant re­form that would dra­mat­i­cally im­prove the Amer­i­can health­care sys­tem right now and could be the bridge to more com­pre­hen­sive re­form down the road. And it could just be the win that Congress and the Amer­i­can peo­ple need right now.

Dr. Matthew Hahn prac­tices fam­ily medicine in Han­cock, Md., and is the au­thor of Dis­tracted: How Reg­u­la­tions Are De­stroy­ing the Prac­tice of Medicine and Pre­vent­ing True Health-Care Re­form.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.