Category: Healthcare business

Oh, you want to get a Covid test, do you? Little did you know that the clever people who do these things also give you endurance, patience and intelligence tests at the same time! Our wonderful healthcare people and helpful governments have somehow arranged a diverse number of ways to make you fill out varying forms in varying orders, only to find out that there are no available appointments.

Don’t you think the highly paid experts who created these services could have done something simple, like following the model of dimensional search used at little places like Amazon, travel sites and other places that care about customers? I guess that would have been too easy or something. And besides, medical scheduling in general is a nightmare, why should this be different?

Looking for a test: CVS

Search told me that my local CVS has testing. I clicked to the website of my local store. I clicked “schedule a test.” Although I had come from the local store, I guess the people who built covid testing didn’t manage to get the local site to pass on its location, so I entered my location again as requested.

Now I have to “answer a few questions” for no-cost testing. Eight questions. Then when I say yes to recent symptoms, 12 more questions plus the date my symptoms began. Then clicking that I was truthful.

Next, pick a test type, look at a map of local stores and see a list of dates starting today. I pick today. There’s a list of each store, with a button under each to “Check for available times.” Click on the first store. Here’s what appears:

There are no available times at this location for Tue., 12/21. Try searching for availability on another date.

Wow. I go up and pick the next day. Click. No times. Pick the next day. Click. No times.

CVS has pioneered a whole new way to help customers pick a time! You pick a date, pick a store, click and hope you get lucky. Then pick a different store and/or a different time and click again. And keep rolling until you hit the jackpot! Assuming there’s one there…

Since there was no end in sight, I tried something different.

Looking for a test: Walgreens

No questions first. Hooray! Just put in a location, pick a test type and see a list of locations. … Almost all of which had “No appointments available.” Let’s check out the one nearest to me, which said “Few appointments available.” I click. First I have to agree to lots of things. Now I have to enter my full patient information: name, gender, DOB, race, ethnicity, full address, phone and email. Then review and click that it’s correct.

Then, it’s the covid questions: my symptoms, contacts, medical conditions, pregnancy. Have I had vaccines? For each, which one and the date given. Have I tested positive in the past?

Now, after all that, I can pick an appointment. Back to that bait-and-switch first screen with test types and locations. I pick the location. Now a calendar shows up. Today’s date is highlighted. This message in red is below: “No time slots available within the selected date. Try a different date for more options.” The next 7 days are in normal type, beyond that they’re greyed out. Do any of them work? I try each day individually. They each give the same message! Why couldn’t you have told me that NO DATES WERE AVAILABLE!?!? Maybe even … BEFORE I filled all that stuff out??

Looking for a test: The state of NJ

Since I live in NJ, I get regular dispatches about how the state government cares about my health in general and covid in particular. So I went to the state site.

Which it turns out is operated by a private company, Castlight.

I put in my zip code. They list places that offer testing, one of which is the Walgreens I just tried. But I click on it anyway, and they link me to Walgreens testing … in a town 10 miles away instead of my town, which was explicitly the one I clicked on. Good job!

They got my hopes up by listing Quest Diagnostics, which has a location in my town. I answer a long list of questions and am told that I quality for a test! Hooray! But then …

I have to sign up and provide loads of personal information before even knowing I can get a test. That’s it for Quest.

Looking for a test: The local county

Maybe my local county would have done it better? Let’s check it out.

I get a long list of testing places. How do I find one near me? After a few minutes of confusion, I discover that the sites are listed alphabetically! Now that’s helpful!

CVS of course is near the top, with a line per location. My town isn’t listed even though I already know that the local CVS claims they do tests. Crap.

Looking for a test: Digging deep

I found a private place, Solv, that claims to link you right to testing places. I tried. They had a clinic not too far from me. Clicked. I’m still on Solv, which is potentially good. After more clicking It turns out that no appointments were available today or tomorrow, the only choices. Gee, Solv, maybe in the next release of your software you could possibly only show choices that were actually, you know, available??

I finally tried a little pharmacy that is local and has remained independent. They offer tests. I clicked and got to a page dedicated to the pharmacy under a place I’d never heard of, Resil Health. Right away they list dates and times available. Just a few days out.

I pick a date and enter the usual information on a clean form, but also my insurance information and a photo of the front & back of my card. Click. The time is no longer available! But at least picking another time was easy. I was disappointed that it was a couple days out. They sent an email with a calendar invite. I accepted. There was a link to reschedule. I tried it. To make a long story short, sometimes when I clicked reschedule the dates available changed, and earlier ones appeared. After some effort I snagged one the same day! Then I went. All I had to do was show my driver’s license – since they had everything else, neither I nor anyone at the pharmacy had to do paperwork – Resil health did it all, including the reporting.

It was a pain, but by far the best. Hooray for small-group entrepreneurs, getting a service up and running that makes things easier and better than any of the giant private companies and certainly any of the pathetic ever-so-helpful governments.

Looking for a test: Is it just me?

I had to wonder: is New Jersey particularly bad, as snotty New Yorkers like to joke about, or is it just the way things are? It turns out that, even in high-rise Manhattan, covid testing is tough. This article spells out the issues.

Mayor Bill de Blasio keeps telling New Yorkers frustrated with long waits and delayed results at privately-run COVID testing sites to use the city’s public options — but his administration’s incomplete and bulky websites make that exceedingly difficult.

It’s not just me.

Conclusion

I got my test. I’ll get the results soon. Let's hope getting those results is better than it often is in medicine. What’s the big deal? I’m only writing about it because it’s a representative story in the life-in-the-slow-lane of typical software development. It’s possible to write good software. Thankfully there are small groups of motivated programmers who ignore the mountain of Expert-sanctioned regulations, standards and processes that are supposed to produce good software. These software ninja’s have a different set of methods – ones that actually work! For example, in New York City:

The complaints echo the problems New Yorkers encountered when city officials first rolled out their vaccine appointment registration systems this spring — prompting one big-hearted New Yorker with computer skills to create TurboVax to workaround the mess.

“We don’t have a single source of truth for all testing sites in NYC,” tweeted the programmer, Huge Ma, who was endearingly dubbed ‘Vax Daddy’ by grateful Gothamites. “Tech can’t solve all problems but it shouldn’t itself be a problem on its own.”

One guy – but a guy who actually knows how to produce effective, working software in less time than the usual software bureaucracy would take to produce a first draft requirements document. This is one of the on-going stream of anomalies that demonstrate that a paradigm shift in software is long overdue.

It’s easier by far to make a reservation at a restaurant than for a medical test. I guess having a meal at a restaurant is far more important than getting an MRI, given that the restaurant people have made the process simple and convenient and effective for all concerned. Getting a medical test must be rare and unimportant, since no one has bothered to make it work well. Sure. I guess that lie is more comfortable than the other possibility, which is that medical system administrators and software providers are too incompetent, lazy or unmotivated  to make things moderately convenient and up-to-date for their employees and customers.

Why this is an important issue

If you’ve gotten this far, you’re already an unusual reader. The vast majority of the leaders, innovators, experts and generally high-prestige people in healthcare would have tuned out and moved on as soon as they saw “medical scheduling.” Their guts tell them “medical scheduling isn’t important.” In terms of career growth and industry prestige, their guts are serving them well.  However, in terms of making a real difference that will positively impact most people involved in medicine, their guts are misleading them.

Medicine has a real prestige problem. I’ve described the medical innovation spectrum, in which the exotic, future-oriented end, like AI and Blockchain, gets most of the money, conferences, attention and career-advancing opportunities. The more you move on the spectrum to simpler, proven, non-exotic things that can make a difference here and now for lots of people, the more you’re moving to the back office or basement, where poorly-paid, invisible people while away their time and whine to no meaningful audience. Here are details and examples.

Scheduling is one of those proven winners that remains largely unimplemented in major medical organizations. The fact that scattered medical groups have implemented it beautifully shows there are no technical barriers.

I can hear it now. Scheduling. Sure. What award am I going to win by implementing something restaurants do? I’m breaking new ground in personalized medicine while I’m curing cancer on the side! Away with your trivial scheduling talk!

I get it. There’s just a little problem. As I’ve detailed here and here and here and here and more, time and money loss and serious medical issues are caused by nuts-and-bolts problems in the medical system. If just some of them were improved, the funding for your precious futuristic projects could be increased! And, by the way, loads of patients would be better off on multiple dimensions, including not dying prematurely! You know, little things.

As an example of the impact, consider just this aspect of scheduling: automated follow-up (yes, it’s part of scheduling). Failure of follow-up problems:

“The impact on patient outcomes included missed cancer diagnoses.” Journal of General Internal Medicine.

“In fact, almost a quarter of all medical errors occurring in outpatient settings can be attributed to poor follow-up of abnormal test results and are believed to represent 25% of malpractice lawsuits involving failures or delays in diagnosis.” AACC

The Scheduling problem

There are an amazing number of dedicated, skilled, hard-working professionals in medicine. There are patients who have health issues who are often grateful for the service and care provided by those professionals. But both groups, providers and patients, are burdened by ancient, dysfunctional and incredibly expensive processes and computer systems that make things that should be quick and easy into something that is cumbersome and time-consuming, often yielding poor results. Everyone involved feels trapped and needlessly harassed. What’s going on here?

This is the horrible general scheduling problem in health care. To illustrate the issues in a concrete way, I’ll focus on scheduling a test as a follow-on to a procedure, and use my own experience as an example – an example that, sadly, is business-as-usual in this world.

A Cat Scheduling Example

Before getting into scheduling a medical test for me, let’s see what happened when I had to schedule a test for someone more important than I am – at least she seems to think she is – my cat, Priss. The comparison between getting tests for Priss and me will be instructive.

I have a cat, Priss. Priss is pretty chill; here she is thinking deep thoughts:

I take Priss to a local animal hospital, where she is well cared for. I get regular notes and emails telling me when something medical needs to be done for Priss. For example, here’s the header of an email I received last year:

Note that the email arrived near the end of August, 2018.

Here’s the top part of the mail:

Note that there’s a picture of a cat in the email – they know who they’re dealing with! They know Priss’s name, and they know she’s a cat, and not one of those friendly but face-licking, slobbering dogs who are incapable of using a civilized thing like a litter box.

Here’s the rest of the email:

They make it hard to miss the phone number or the online scheduling system they support to make an appointment, don’t they? They also spell out exactly what needs to be done. And darn, the email was sent EXACTLY one month, to the day, before the service was due. Please note: this is THEM taking the initiative to follow up, TELLING ME when something needs to be scheduled.

If this were a human hospital we were talking about, I would say “to make a long story short …” but because this is an efficient, modern animal hospital, I get to say “to tell it like it is …” all I had to do was click on the email, buzz through their easy-to-use on-line scheduling system, make an appointment that worked for them and for Priss, get a confirmation email back right away, and I was done. That’s it!

On top of it all, the people there are great, and care for Priss really well. There was a problem with her fecal test — results back in a single day — and the treatment was immediate and effective, no more than a day's delay for any step.

An MRI Scheduling Example

Now we turn to hospital scheduling for humans, specifically for me at the world-class hospital system, Mount Sinai. I’ve had some medical issues that have required MRI testing. See this for a description of the issue, with details about the testing experience and the conclusions that can reasonably be drawn from it.

I had  30 days of radiation therapy in early 2018. I was supposed to have MRI’s to see the results of the radiation six months and a year after the treatment. This is standard practice. I know from experience that the grandees at Mount Sinai Medical System haven’t gotten around to sending a team to the Hudson Animal Hospital to learn from their cat scheduling system, so they can put a multi-year project plan in place to implement something similar for their human patients. In a human medical world that worked as well as my local little animal hospital, I would have gotten a reminder a month before my MRI should have been taken.

Being the patient patient that I am, I waited until after the anniversary itself. Then I sent a friendly reminder to my doctor:

He replied the next morning with a perfectly reasonable response – given that he had to do the work that a vet wouldn’t have had to do.

His prompt reply was Feb 4. I heard nothing for weeks, so I finally reached out again three weeks later:

Again, the doctor in charge of the radiation center, doing clerical work well and promptly, work that he shouldn't have had to do, responded right away:

What happened next? More fun wasting everyone’s time. Remember, with a reasonable on-line system like restaurants and vets have, none of this would be needed!

A couple days later I got a voice mail, with a friendly person giving me the date and time for which my MRI has been scheduled – of course, without consulting me! I guess I must be sitting around suffering, anxiously waiting for the first possible moment at which I can get my MRI, at which point I’ll drop everything and arrive two hours early. Or not. Even better, this call isn’t from the MRI center, it’s from my doctor’s office, where someone has made an appointment for me, a couple days after the most recent request, weeks after the original one. So I return the call, explain I can’t make the appointed time, and is there any way I could talk with the MRI center and make an appointment myself? Well, she tries to be accommodating, and says it’s OK, but I also need to make a follow-up appointment with the doctor by calling her. I think I can manage this.

I call the number she gives me, which was the wrong number. I consult the web, and it takes a typically long time to find the center and its phone number for scheduling on the website. Mount Sinai management, it goes without saying, is totally on top of customer feedback and quality management. So they pop up an opinion survey. What happened with the survey is a lesson all by itself in the profound dysfunction of our medical systems in general, and Mount Sinai in particular. I will treat this event in a separate post.

I call what the website says is the right number, and keeping sarcasm – however warranted it may be – to a minimum here, after a journey through automated VRU’s and other wrong numbers, I eventually get to the person who can schedule me. Sure enough, she finds the order for the MRI in her system, and makes an appointment that actually works for me. Phew! I then, as instructed, call back the main doctor’s office and schedule a visit with him to go over the results, as I had been instructed to do. Please note this visit with the doctor I scheduled; it will start its own little trail of incompetence and waste.

After way too much effort on everyone’s part, I thought things were finally set. Silly me. I got this call a few days before my MRI appointment:

After a couple of attempts, I get through. I’m told that the room where the MRI machine is suddenly needs to have major work done, work that apparently couldn’t be scheduled in advance, making the machine itself unavailable. So pick another time. We work something out. I then call the doctor’s office and re-schedule my visit with him, so that it’s suitably after the new date of the test.

On the morning of the date of my original doctor visit, the one I called and re-scheduled, I get a voicemail saying in effect, “you’re coming into today as scheduled, right?” I admit that the nasty thought of ignoring the call crossed my mind, but my better self took control. I called and got through after a couple tries and explained the re-scheduling. The person verified that the new appointment had in fact been made, but that “someone else” must have failed to cancel the old one. Done. Except that it wasn't really "done." See the associated customer service post to see what happened!

A week later something came up and I had to move the appointment with the doctor. I called. After explaining what I wanted, the person said, didn’t you just miss a scheduled appointment with the doctor? Nope. Apparently the last person I talked with, whom I told about their mistake, failed to correct it. Again.

Do you use a calendaring/scheduling system, for example the one in Microsoft Outlook? Have you noticed that you can click on an event and change the date/time, so that it moves to the new time slot? Of course, you can delete the old one and make a new one from scratch if you really want to, but why would you? The evidence seems to point to the possibility that such a feature, which is standard on modern calendar systems, doesn’t exist in the paragon of modern software used by the leading medical system, Mount Sinai.

Conclusion

Follow-up of events, both one-time and multiple recurring, is a standard feature of modern scheduling systems. Self-scheduling by software is a widespread feature. It’s widely used, and benefits everyone involved. It’s not as though self-scheduling by software is particularly difficult for medicine. For example, the primary care office I use, OneMedical, has a convenient system that takes account of the length of visit you need, and gives you choices of providers and locations so you can pick what works best for you.  Once scheduling is on-line, it is amenable to serious optimization techniques, which have been deployed with great success resulting in substantial savings and efficiencies in things like infusion centers and operating rooms. This is not possible with the primitive human-phone-based systems in widespread use.

It’s painfully obvious that the important people at medical centers prefer to spend time doing “important” things at the fancy future end of the innovation spectrum, rather than lowering themselves to implement practical, here-and-now improvements that benefit everyone. When will this change?

I've gone through quite a bit to get the results of my MRI. See here for the previous installment, and here for the start of the saga. I glanced at the report and it looked good. In this post, I'll describe the unsettling things I found when digging deeper. In sum: the whole baroque nightmare of scheduling, performing and delivering results of medical tests is not only inefficient and riddled with needless high cost and waste, but more important there are serious quality problems leading not just to delay and waste, but bad results.

I fully acknowledge that what has happened to me pales beside the waste, incompetence and fraud that pervades the worst medical systems. My point is that, even in the best healthcare systems, bad things are happening.

The Results

I glanced at my hard-won test results and felt OK, mostly because I had been told that radiation therapy took a looooong time to show results, and I shouldn't expect anything to change at the first MRI. There was no OMG or IT'S GROWN LIKE CRAZY in the notes when I glanced at them, so I let it rest. I was tired out from all the effort of getting the darn thing.

Then I looked more carefully. I'm still OK for my personal case, but on close examination, I realized that the final report of the MRI was consistent with the crazy things that led up to it: scheduling the test, taking it, and getting the results. It's all part of a bizarre system that has GLARING flaws that seem like they should be easily fixed, but nothing much happens.

Here is the key paragraph from the earlier of the scans, the one that led to the radiation treatment:

Here is the corresponding paragraph from the second scan, the one I struggled to get:

The first thing that jumped out at me was the simple observation that there are no standards! Radiologists are incredibly smart, well-educated people. College degrees. Super scores on GMAT tests. Degrees from incredibly-hard-to-get-into medical schools that have TINY numbers of students. Then more years getting further training to become medical imaging specialists — usually five more years, on top of the four years of college and the four of medical school! 

If I showed you the whole report, you'd immediately see that even the paragraph and subject-matter organization was different. About the most glaring thing to me was that the second report gave actual dimensions of the tumor, while the first did not! Don't you think that when tumors were involved, specifying the actual size would be the standard?

There's lots more that could be said, but I'll leave it with these simple observations:

• There is no system in place to record and assure that the required location is being imaged. The key thing can be missed because it wasn't imaged.
• There is no consistency of exactly what is reported on and how it is reported. It is difficult to compare reports and assure that what you need is there.
• For tumors, there is no consistent positioning and measurement of size. You could miss a tumor altogether, and easily miss size/location changes.

Conclusion

I'm in remarkably good shape, having a scary diagnosis of an extremely rare cancer. I received great treatment from highly skilled professionals at every step of the way. I received chemo that had only 25% chance of working, but it shrank a rapidly growing tumor. Then, when it started growing again, I got right into radiation, which has at least prevented further growth, and should finally stamp it out. I have nothing to complain about, and a great deal to be thankful for, including all the professionals who treated me. 

I've written this series of posts about Medical Testing NOT as an indictment of the individuals who have treated me, but as a serious indictment of the system in which they work. Here is a summary list of the things that "could be improved;" details are in the prior posts of this series:

• Scheduling and getting a pre-auth for a test can be a labyrinth and delay-filled nightmare.
• There are multiple issues with the wasteful, expensive and time-consuming blood test.
• There are multiple issues with specifying and following an exact procedure for the location and mechanism of the scan itself. Instead of being in the system, the nurse has to get information from the patient and guess about other things!
• The equipment and software is built in a regulation-protected bubble, which results in 10X or greater cost and trailing-edge technology.
• Getting results that have already been created by the radiologist can be an obstacle-filled maze, even if you try to use a “patient portal” that is supposed to make things to easy and transparent.
• The patient portal is mostly a sales pitch about how the hospital is wonderful – getting the information is a big problem, and then important information is wrong or just plain not there.
• Finally, the results produced by super-highly-trained doctors based on these expensive and questionable inputs don’t meet any modern standard for content.

Why doesn't anyone in management seem to care? I've often wondered this, and speculated about why several times. What's clear is that there's a hierarchy of prestige in every society, including ours, and that the top of the hierarchy is populated by people who focus on strategy, policy, direction and messaging. They are, for the most part, "above" getting "lost in the weeds." Sorry guys; the action is on the ground, where real things happen to real people. That's where you discover what's wrong, and when you "fix" something, that's where it's got to change.

Before you get a medical test, it has to be scheduled, right? Just like getting a reservation at a restaurant, both you and the place you're going have to agree on a time. Here's the real-life story of my recent MRI, starting with scheduling it. The point of this post isn't to whine about what happened to me, but to illustrate deep, widespread problems in the medical business by means of a concrete example.

Background

First some background. My doctor was at Mount Sinai. While he was treating me, I had several MRI's at Mount Sinai. Then he moved to another major hospital system in the NYC area, Northwell Health. Both are excellent places with modern, up-to-date systems. I told the story here of the amazing breakthrough in EMR electronic interchange that allowed me to get the MRI's that had been taken at Mount Sinai and get them to the doctors at Northwell so they could do their jobs. It was true breakthrough technology, since the interchange was almost completely electronic, with the truly minor annoyance of a dozen phone calls, a couple paper forms and faxes, and a couple packages carried by hand. I know it's hard to believe that such giant systems could be so modern and electronic, which is why I give all the facts and associated proof here.

I felt my tumor growing again. I quickly got an MRI that showed that, unfortunately, I was right. My doctor, the MRI and the follow-on to it were top-notch. The subsequent billing events are an object lesson in how the business of medicine can be improved, see the posts here for details.

My doctor, who had treated my tumor and greatly reduced it with chemotherapy, now felt it was small enough that radiation was the best approach for treatment. He recommended I go to a radiation specialist, who happened to work at Mount Sinai, my doctor's former employer, and where I had originally been treated. Naturally, I took his recommendation. I got radiated. 30 times.

It is standard practice to check the results of radiation 3 months after the treatment. In my case, that meant getting an MRI.

Scheduling the MRI

Here's what I went through to get the appointment. Nothing horrible here; I'm pleased that something so effective as MRI technology is available and that I was able to get it. But the cost, time and convenience all reflect a broken business model. Fixing the model isn't hard in principle, but would require serious change. This is an example of how it works today.

On my final visit with my radiation doctor post-radiation, he told me about the follow-up MRI I should have in 3 months. He told me his office would contact me and get it scheduled "shortly."

Nothing happened. I waited for the 3 months to pass. No one contacted me. Fortunately, I kept track of the time, so I got on it myself.

I started with my radiation doctor's office at Mount Sinai. Sure, they said, you can use the Northwell imaging center to get your MRI. It's convenient for you, so why not? We'll set it up for you.

I wait a few days. Nothing. I call again. Oh, sorry, we'll set it up. I wait a few days. Nothing. I tried again. Nothing. Finally I called the Northwell imaging center and explained the situation. Sure, no problem let's make the appointment. What about the pre-auth? Oh, don't worry, we'll take care of it. You've got all my information in your system from last time, right? Yes. Don't worry.

Two days before the scheduled MRI, I get a call. Hey, about this MRI you're scheduled for, there is no pre-auth for it, so we're going to have to cancel the appointment, there's not enough time to get one. Great. I don't bother complaining, what good would it do?

I realized that I had been totally wrong in my strategy about this. This medical stuff must be making me lose my mind. Or I'm getting colossally stupid. What was I thinking?? I was choosing where to get my MRI done based on what was best for me. WHAT an IDIOT I am!! I know that the smart thing to do is always do what's best and easiest for the medical system. Duhhhhhh!!

Having returned to sanity, I called the Mount Sinai radiation doctor's office. They said they'd set it up. The whole thing, pre-auth and appointment. A couple days pass. I call again. Same thing. A couple more days pass. I call again. Oh, sorry, excuse excuse excuse. I said, no problem can you just please send me the doctor's order? After more shenanigans, I get the order. Giving in completely to the world as it is, I call the Mount Sinai imaging center, where I've been a few times in the past, and make the appointment, making sure that they've got the doctor's order.

Conclusion

I got the appointment. That's the good news. I know that others have had it far worse. But I also know that this peculiar state of affairs, where there's no equivalent of, say, the Open Table scheduling service for making MRI appointments, is a HUGE time-waster for everyone involved. Do you want a job doing what the people I talked with on the phone sort of try to do? Would you want to cope with constant hassle and frustration?

My insurance company knows the treatments I've had. All the information is in the EMR's of the two major systems I've used. It wouldn't be hard to know that getting an MRI at my stage of treatment is something to authorize. The process could be completely automatic. And I could maybe even have made my MRI decision based on my needs rather than the peculiarities of a deeply flawed, broken system.

Next step: getting the MRI.

Making fun of medical billing, as I have done with gusto in the previous series of posts, is way too easy. Everyone involved knows it's a problem. But it's not getting better. Money that should be spent helping people be healthy or get healthy is instead being spent in completely unproductive ways, annoying and harassing everyone along the way.

It's amazing how many issues are illustrated by just two bills from one healthcare system. Sadly, this is not an isolated example: it illustrates business-as-usual in healthcare billing.

I make no claims to be comprehensive, but fixing the medical billing issues I've illustrated would be plenty!

Here are the prior posts:

https://blackliszt.com/2018/07/medicine-as-a-business-billing-overview.html

ttp://blackliszt.com/2018/07/medicine-as-a-business-billing-1.html

https://blackliszt.com/2018/07/medicine-as-a-business-billing-2.html

https://blackliszt.com/2018/07/medicine-as-a-business-billing-3-insurance.html

Here are some of the highlights:

• The first obvious issue that makes medical billing different from the rest of the world is that there are no price lists. You have no idea what you will have to pay. When you sit down at a restaurant, you get a menu with prices. Not in the medical office.
  
• The next glaringly obvious issue: unlike most other services you can think of, the bill was not presented at check-out time! Fixing this would fix a whole host of problems!
• A single health network has multiple billing systems, each amazingly different from the others, each with its own staff, software, costs, etc. It doesn't have to be this way.
• The bills can arrive months after the service was rendered. What service organization you interact with lets billing slide for months? It sure sends a message that they're not serious about collecting.
• When the bill arrives, the address that it comes from and the place to which you send the payment can have totally different names and places from the organization that served you.
• When you get a bill, you sort of expect to know exactly what the bill is for: what service was rendered, when it was rendered, where and by whom it was rendered. Without those key facts, how can you be sure about the bill? Both bills were a strike-out on this subject. Why is it hard to provide this simple, common-sense information?
• For many people, receiving bills and paying electronically is convenient. For many organizations, sending bills and receiving payment electronically is more efficient, and encouraged. As I've illustrated in these bills, the health system's electronic payment is like a programming 1.01 course project — one that failed.
  • They didn't even try to have e-bills.
    
  • E-payment was offered on the paper bills, but the process was amazingly bad and error-prone.
  • In the end, e-payment simply did not work. Period. And of course, there was no electronic way to get help or even register a problem!
• The second the insurance company is involved, things get real baroque in the bills, with confusing additional information that, in the end, makes no difference to the patient. And without even the name of the insurance company correct.
  

Wow-za! Not that any self-respecting healthcare system manager will spend money on fixing billing instead of promoting innovation, AI and ML anytime soon! Why, if they stooped to merely making things better for patients while reducing costs, they would rapidly lose prestige among their peers in the industry!

In the prior post in this series, I presented a couple bills and dove into detail for one of them. Now it's time to see what pleasures there are in the second bill.

The doctor visit bill

Here’s the bill I got for a visit with the doctor who ordered the procedure:

This bill is a bit of a relief compared to the one for the MRI. While the return address (some PO Box in New York) and the address to which payment should be sent (NSLIJ at a PO Box in New York) are opaque and confusing, at least the box in the middle of the page names the doctor I saw and gives the date of the visit. I know what I'm being billed for: a visit with this doctor on that date. That's good!

Let's look a little more closely.

First, there's something interesting about the date. The visit with the doctor was Dec 11. Now look at the statement date: 3/13/18. Yes, that's right: the statement was dated a full 3 months after the visit! Wow. Northwell has clearly optimized their systems to march everything through so they can bill and receive payment promptly, right? Sadly, no.

Second, I'd like to point out an important issue: paper vs. electronic. With all the noise, billions of dollars of federal subsidies, and the obvious fact that electronic is better than paper, you would think that a major NYC hospital system would be entirely electronic. You would be wrong. Here is a post about this. But about this bill:

I got the paper bill in the mail. They could have gotten my email from me at any time, but didn't.

There is no opportunity to sign up for paperless billing, unlike even notoriously backwards bureaucracies like utility and phone companies, which constantly harass you to sign up.

Two things on the bill are highlighted to make them stand out: The amount to pay and the URL to pay it:

I think it's fair to say they're trying to get me to pay online. So I tried. But what a pain! Copying that looooooong URL without error isn't trivial. Then once I entered it correctly, here's where I landed:

They re-directed me: that long string I copied could have been tiny, because it wasn't actually the place they wanted me to go!

But the fun has just started. Now I have to fill out the form:

Once I filled it out, here is the result (with my DOB cut off for privacy):

Fail!

Dutiful person that I am, I got out my ancient check book, revved up my hand-printing skills, and … yes, put the check in the mail.

There is more joy and fulfillment to be found in this simple-seeming one-page bill, but that's enough for now. For the next installment, we can look forward to some only-in-healthcare wonders of billing.

If you were to argue that my fascination with medical billing, including the endless-seeming minutia of it, is somewhat, well unusual, I could not dispute it. "Guilty as charged" (or billed?) would be my only response.

I've learned that the obvious, annoying uniqueness of paying for medical services, different than pretty much anything else in our lives, is the tip of an iceberg of financial pain, metastasizing bureaucracies and festering IT dysfunction for the institutions and people involved in it. See this for some context.

This is a strong, broad statement. Let's dive into some real-life, on-the-ground facts and see what we see.

Background

I’ve been under the care of an excellent doctor, now working at Northwell Health, for a super-rare, long-term condition. I called his office because there was evidence that the condition was worsening. His similarly excellent NP buddy responded to my phone call report by authorizing an MRI of the area in question, and making an appointment for me to see the doctor 4 days later. I truly appreciate how exceptional this accessible and responsive behavior was.

I went to the MRI and then had a consult with my doctor. Sure enough, the evidence I noticed was confirmed by the MRI, and he immediately started the appropriate treatment.

From a medical and scheduling point of view, this experience would be hard to beat. Anywhere, under any system.

This post, however, is about the hospital system billing, with the heavy involvement of my insurer. Every step of the process was chock-full of stupidity, waste, friction and “opportunities for improvement.”

The bills

Here’s a bill I got for the MRI:

Here’s a bill I got for a visit with the doctor who ordered the procedure:

Take a quick look at the two bills, each issued from the same health system for visits which took place in Manhattan a few days apart. Could they be more different?

Right from the get-go, we know we have a problem. Totally different systems producing bills that are radically different, involving different systems for generation, tracking, and collection. Wow.

Totally different systems

Even though both bills clearly have the Northwell Health logo clearly displayed at both the top and bottom of the page, nearly everything else about them is different. The return address is different, the address to which you send the bill is different, even the little box where the payment is defined is different. It blew me away that even the web page for electronic payment was different!

This means different software systems for generating the bills and collecting the payments, among other things.

The MRI bill

Let's look at that MRI bill. It's written in the form of a letter, which is interesting. It was amazingly prompt: the "service" was "rendered" on Dec 7, while the bill was dated Jan 13, only 5 weeks later. In terms of medical billing, lightning fast!

Who is the bill from? Clearly, Northwell Health. But that doesn't help, because Northwell is a giant system. The return address of the bill says "Lenox Hill Hospital," with a PO Box in New Hyde Park, NY. That's nice, except that there is no place called "Lenox Hill Hospital" in New Hyde Park — though there is a huge complex that is part of Northwell called "Long Island Jewish Medical Center." So where is "Lenox Hill Hospital?" That's easy. It's a big place on E 77th St in Manhattan. The addresses they give aren't helpful. What about the letter itself. Maybe there's a hint there?

Now we're getting somewhere — the letter clearly states when and where the service was performed:

Excellent, the service was performed at Lenox Hill, the place on the Upper East side of Manhattan. The trouble is, I didn't go there for my MRI!. Not there, and not LIJ. I went to an imaging center run by Northwell in the Chelsea neighborhood of Manhattan.

Maybe they're talking about something else than my MRI. Let's check out that bill again, and see for sure that it's a bill for my MRI. Uh-oh. Trouble. Nowhere is MRI mentioned in the bill, or medical imaging of any kind! Look again at the bill and the snip of it above. The words used are "services rendered." The wonderful people at Northwell go to the trouble of putting a Spanish-language version of the bill on the other side of the paper, but they can't be bothered to tell me what service was provided or where it was provided. Actually, it's worse. They clearly state in the snip above that the service was provided at Lenox Hill Hospital. Which it was not.

Now try to pay the bill. Hah! They give a website. Let's go there.

I have to guess that they want me to pick "hospital," so I do and pick the one on the bill, Lenox Hill. I hit "submit." Here's the result:

Software is wonderful, isn't it?? Saves trouble, filling out paper, stamps, and all that old-fashioned stuff. Just go on-line and pay. Except when the software doesn't work.

That's plenty for a single blog post. We'll have some fun with the other bill next.

If you break your arm, broken arms are suddenly at the top of your list of least favorite subjects. But after the arm gets better, the billing process for the arm-fixing services is probably pretty high on the list.

Medical billing is something too many of us are way more familiar with than we'd like, but nonetheless will serve as an excellent first subject for this series on the business of medicine.

Let’s start by putting medical system billing in perspective.

Going to a hospital or doctor to get a service is in most ways like going to any place and getting a service.

• You’re hungry, you go to a restaurant and get a meal.
• You’re shaggy, you go to a barber or salon and get a cut.
• You’re bored, you go to a movie or show and get entertained.
• You’re bored and hungry, you go a bar with a show
• You need a book or chair or laundry detergent, you go to the appropriate store.
• For most of the above, you just go. Sometimes, when the service is popular, it pays to make a reservation. You call or do it online, and your space at the place is assured.

A pattern is clear here. When you need something, you go to the place that has, does or serves that thing and you get it. Pretty simple, and universal. Same thing with medical issues!

• You broke your leg, you go to the hospital and get it fixed.
• Your skin gets weird and painful, you go to the doctor and get it checked out.

But there’s something really important that I’ve left out of the above list; I suspect you know what it is. Let’s see if you’ve guessed what it is. I’ll wait and give you some time. Click … click … click … OK, time’s up! Did you get it? You probably did, but just in case, here’s the answer:

The billing and payment are totally different! And the scheduling/reservations are often a nightmare!

Here's how it works for nearly everything:

• For the movie, the price is posted, you pay when you enter.
• For the restaurant, salon, and retail store, you choose from a menu or list or wander around picking things, and pay when you leave based on the services/goods you got.
• For the bar with show, you pay the cover charge when you enter, and your bar tab when you’re done drinking/eating.
• For all of these, you can pay with cash or card. The card could be a credit card, which enables you to pay later or make payments.

Now, let’s look at the big exception: medical billing.

• If it’s an emergency, you might go to the ER and wait for hours.
• If not, making that “reservation” may require a “pre-auth” and a variety of other things that are often painful, and sometimes denied.
• You don’t pay when you enter.
• There are no posted prices, unlike the salon or movie. No menu. No price tags.
• Some stores let you special order things, sometimes one-of-a-kind. Before getting it, you get a price and make a payment arrangement. Not in medicine!
  
• There is no “check-out register” where you find out what the total comes to.
• Unlike a restaurant, where no one has any idea what food and services you’ll receive when you walk in, there is no bill at the end.
• In medicine, it’s common to leave after services have been rendered, and eventually a flurry of bills may arrive from different places and/or notices from insurance wanting information or telling you what’s been “covered” and what they’ll pay.

Go. Get services. Leave. They're all the same. Schedule it and pay for it: it's totally different in medicine!

• “I broke my leg” is like going into a car repair shop knowing you want it fixed, but not being able to do it yourself or knowing what it will cost. It’s your only car, so it’s got to get fixed.
• The car place tells you about what it will cost and you agree to pay when done. Not so at the leg fixing place!
  
• Bills from the ER and a couple doctors could show up over the next couple of months, with lots of fine print. The insurance company probably joins the fun with multiple pages.There's loads of stuff that has no counterpart in the real world of product and service buying.
  
• “I have funny skin” is like going into a salon knowing your hair and makeup just doesn't work for you, and you don't know what to do. You need a new "look" and need help and advice. After a discussion you might look at some pictures and try a couple things out. A specialist may need to be called over.
  
  • You get your new look and pay for the products and services on the way out of the salon. Not so at the skin fixing place!
  • There might be "co-pays" that you owe someone, or maybe not if they're "in network." Letters about any "coverage" some family member may or may not have. Not to mention surprise bills. Nothing that any salon of any kind would ever try if they wanted to keep their customers.
    

All of this is bad. Really bad. It's terrible for patients, terrible for medical people and institutions, and no fun at all for insurance companies. Believe it or not, the behind-the-scenes, underlying reality is even worse! Which is part of why it doesn't get better.

In the later posts in this series, I will go into specifics with real-life examples. In each case, while there are clearly systemic barriers to improvement, there is a clear path to improvement.

Among the issues I'll cover are these:

• The delay between the service and the bill
• Bills from different places
• The difference between provider billing and insurer paying
• What service was provided, where and by whom?
• The challenge of paying the bill

This is going to be fun!

Medicine is a business. It’s a big business. But it’s like no other business, often in ways that are not good for anyone involved.

The good news is that there are many amazing people who work hard, have compassion, and do their best to make things better for their patients. More good news is that dedication and hard work have created drugs and procedures that can cure or alleviate awful conditions, conditions that resulted in pain, suffering and premature death in the past. We are truly blessed.

It’s not news to say that the business of medicine could be greatly improved. When this subject is discussed, it’s usually done in terms of rocks and hard places, or irresistible forces and immovable objects. Then hands are waved, thrown up in the air, and nothing but desperate hopes are expressed.

I believe that the business of medicine can be improved. Greatly. From the outside, it’s impossible. But when I look at the computers and software systems and procedures, I find a particularly ripe example of something I’ve seen many times: decrepit software running on outrageously expensive hardware, surrounded by ineffective business processes, and run by experienced, well-meaning people trapped on a steam-age island in a world that has long-since gone electronic. While there is no magic wand to fix everything in a flash, the technology is available to make dramatic improvements. Today.

To a broadly experienced software person, the solutions are obvious – once the exact technical flaws have been precisely identified. Much of this series will be devoted to spelling out those flaws, not to wallow in them, but to put cross-hairs on them so they can be fixed!

As context for the rest of the posts in this series, let me observe that the issues I will raise are waaaay too "little" to engage the big minds and the great powers in the medical industry. These prestigious and powerful people much prefer to give talks, issue press releases and hang banners about how they and their institutions are "innovative," how they are leading the industry in their use of "cognitive computing" or "artificial intelligence." They hold and/or attend conferences on the subject, and pour money in those general directions, each of which is sure to deliver real results real soon now — why, the trials are just so promising!!!

That's not my perspective, to put it mildly. See this for some plain words and facts on the subject of fancy-pants innovation in healthcare. And see this for facts and logic that help explain why this subject gets almost no interest or attention from the higher-ups in healthcare management.