By KIM BELLARD
Larry Levitt and Drew Altman published an opinion article in JAMA Network with the title we can’t argue with that The complexity of the US healthcare system is the enemy of access and affordability. It is based on a Kaiser Family Foundation June 2023 Survey on consumers’ experiences with their health insurance. Long story short: even though – surprisingly – more than 80% of insured adults rate their health insurance as “good” or “excellent,” most admit to having difficulty understanding and using it. And people in good or poor health, who probably use health care more, have more problems.
Health insurance is the target in this case, and it’s a fair target, but I’d say you could choose almost any part of the health care system with similar results. Our healthcare system is a perfect example of a Rube Goldberg machine, which Merriam Webster defines as “accomplishing by complex means what seems to be possible to do simply”.
Hello, my boy.
Health insurance is many people’s favorite villain, one that many would like to do without (especially doctors), but let’s not stop there. Healthcare is full of third parties/middlemen, which has led to the Rube Goldberg structure.
CMS does not pay any Medicare claims itself; it hires third parties – Medicare administrative contactors (formerly known as intermediaries and carriers). The same goes for self-insured employers (which represent the vast majority of private health insurance), who hire third-party administrators (who can sometimes also be health insurers) to provide network management, claims payment, eligibility and billing, and other tasks.
Even insurers or third-party administrators may outsource tasks such as provider credentialing, utilization review, or care management (in its many forms) to other third parties. Take, for example, the universally maligned PBMs (pharmacy benefit managers), which have carved out a large niche providing services between payers, pharmacies and pharmaceutical companies while raising more and more questions about their real value .
Medical practices have a long history of outsourcing billing services. Hospitals and doctors have not developed their own electronic medical records; they have contracts with companies like Epic or Cerner. Healthcare entities have struggled to share data, so HIEs (health information exchanges) have arrived to help move some of that data (and HIEs are now transitioning to QHIN (Qualified Health Information Networks), due to TEFCA).
And now we are witnessing a real Cambrian explosion of digital health companies, each thinking they can take a part of the health care system, bring it online, and maybe make part of the health care experience a little less bad. Or, looked at another way, add even more complexity to the Rube Goldberg machine.
On a recent THCB Gang Podcast, we discussed HIEs. I agreed that HIEs were developed for a good reason and did a good job, but in this supposed the era of interoperability they should try to file for bankruptcy.
HIEs identified a pain point and found a way to make it a little less painful. Not to fix it, just to make it less bad. The healthcare system is full of middlemen who offer workarounds that keep our healthcare system moving forward. But once in place, they stay in place. Health care doesn’t work well with procrastination.
Unlike a real Rube Goldberg machine, our healthcare system has no real design. It’s more like an evolution, where there are no style points, no efficiency goals, just credit for survival. Sure, sometimes you get a cat through evolution, but other times you get a naked mole rat or a hagfish. Healthcare has far more hagfish than cats.
I’m impressed by the creativity of many of these workarounds, but I’m terribly tired of needing them. I am terribly tired of accepting that complexity is inherent to our health system.
Complexity is bad for patients, bad for the people who directly provide care, and only good for every other person/entity who makes a living in health care, because if it is. Instead of making pain points less painful, we should get rid of them.
If we had a magic wand, we could transform our health care system into something much simpler, much more efficient and much less expensive. Unfortunately, not only do we not have such a magic wand, we do not even agree on what this system should look like. We are so accustomed to the complex that we can no longer see the simple.
I don’t have a utopian vision of a healthcare system that would solve all of our system’s problems, but I do have a few suggestions for all healthcare innovators:
- If your solution requires patients to fill out an additional form, log into an additional portal, make an additional phone call, please reconsider.
- If your solution is time consuming by taking patients away from clinicians and having them do other tasks instead, please think again.
- If your solution does not create information that will be shared to help patients or clinicians, please reconsider your decision.
- If your solution only focuses on a specific moment, rather than contributing to an ongoing process, please reconsider your decision.
- If your solution is designed to increase revenue rather than improve health, please reconsider your decision.
- If your solution does not recognize, acknowledge, report, and act accordingly on failures/errors/errors, please reconsider your decision.
- If your solution cannot be simply explained to a layman, please reconsider your decision.
- If your solution adds to the healthcare system without reducing/eliminating the need for something even more important in the system, please reconsider your decision.
- If your solution directs care to certain clinicians, in certain locations, rather than seeking the best care for the patient in the best location, please reconsider your decision.
- If your solution adds costs to the healthcare system without uniquely and specifically reducing costs even further, please reconsider your decision.
- If your solution does not have built-in mechanisms (e.g. use of AI) to be and stay up to date on an ongoing basis, please reconsider your decision.
I’m sure all of these innovators think their idea is very clever, and many are, but remember: just because an idea is clever doesn’t mean it’s not Rube Goldbergian. They need to step back and ask themselves if they are adding to the Rube Goldberg machine of health care or helping to simplify it. I bet they usually add things to it.
So yes, I agree with Mr. Levitt and Dr. Altman that health insurance should be less complex. Like everything else in the healthcare system. Let’s start by taking apart the Rube Goldberg healthcare machine.
Kim is a former e-marketing manager at a major blues plan, editor-in-chief of the late and much-missed Tincture.ioand now a regular THCB contributor.
