Health Insurance Providers: An Unlikely Resource in the Drive for Cost-Effective, Quality Healthcare

Every year in the USA, it is estimated that approximately 250,000 people die annually from healthcare errors, according to a study published in 2016 in the BMJ by Martin Makary, MD, MPH. Health insurance providers of both HMO’s and commercial plans are uniquely posed to lead the way to solving this national crisis.

Health insurance providers have access to every single detail of a patient’s healthcare, because they have been billed for it all and kept claim details of all the healthcare people have received. A contributing factor in not being able to deliver quality healthcare is lack of access to complete and accurate health information across different delivery areas. Different delivery areas include outpatient and inpatient settings, emergency and clinic care, home health, and inpatient rehabs, along with others.

I am not the first person to recognize the potential role insurance companies can play in improving healthcare delivery. Access to records across the spectrum of healthcare delivery is one the reasons for the establishment of Medicare HMO’s. Additionally, accurate and accessible records from all care providers is one of the main reasons behind the establishment of EMR’s.

Then, why hasn’t healthcare improved dramatically since everything is more centralized than before?

The answer is complex. One factor is that there are multiple health insurance providers, including such publicly traded and recognizable names as Cigna-Healthsprings, Aetna, BCBS, and Humana. All of them offer Medicare HMO plans in the USA. All of them are required by CMS to follow strict documentation, communication and billing guidelines to manage patients. Each company has been granted the freedom to do so in the way that follows their own business model and existing claims management and communicate software.

Edwards Deming famously said “Variation is the killer of quality.” While I would argue that this in no way applies to every situation, I would argue that here it does. Theoretically, I suspect the premise behind this HMO experiment is similar to that of evolution. If you think of each HMO and provider as separate organism, and healthcare as a whole as the ecosystem, then “adaptative change over time that results in the most efficient system, as a result of changes in heritable physical or behavioral traits” could arguably be what we have attempted to create. The danger in this evolutionary “sink or swim” mentality to accurate communication among healthcare providers is that the consumers of healthcare suffer. Consumers of low quality healthcare suffer on a mortal level, compared to consumers of low quality goods such as shampoos or dishwashers.

So, what is the solution? I am suggesting a single, standardized EMR and claims management system across all healthcare providers and insurers. I realize that the infrastructure to support this would be enormous, the cost to implement astronomical, the challenges to maintain migraine-inducing, to say the least. Not to mention the anti-trust laws and legality surrounding the monopoly of whatever system was given the contract.

But when you analyze the long-term implications of not going down such a road, the upfront cost becomes more palatable. The cost of a lifetime delivery of poor healthcare, combined with the associated costs of billing and claims management is astronomical. Our country is already spending billions on software maintenance and network infrastructure; lets spend this on something to streamline healthcare delivery.

I acknowledge that such restructuring would have negative consequences, and I will address these negative consequences in a future post.  Please look for such a post over the next 4-6 weeks.

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