Focusing the Health Care Lens

Lead Analyst: Maria DeGiglio

RFG Perspective: There are a myriad of components, participants, issues, and challenges that define health care in the United States today. To this end, we have identified five main components of health care: participants, regulation, cost, access to/provisioning of care, and technology – all of which intersect at many points. Health care executives -- whether payers, providers, regulators, or vendors – must understand these interrelationships, and how they continue to evolve, so as to proactively address them in their respective organizations in order to remain competitive.

This blog will discuss some key interrelationships among the aforementioned components and tease out some of the complexities inherent in the dependencies and co-dependences in the health care system and their effect on health care organizations.

The Three-Legged Stool:

One way to examine the health care system in the United States is through the interrelationship and interdependence among access to care, quality of care, and cost of care. If either access, quality, or cost is removed, the relationship (i.e., the stool) collapses. Let's examine each component.

Access to health care comprises several factors including having the ability to pay (e.g., through insurance and/or out of pocket) a health care facility that meets the health care need of the patient, transportation to and from that facility, and whatever post discharge orders must be filled (e.g., rehabilitation, pharmacy, etc.).

Quality of care includes, but is not limited to, a health care facility or physician's office that employs medical people with the skills to effectively diagnose and treat the specific health care condition realistically and satisfactorily. This means without error, without causing harm to the patient, and/or requiring the patient to make copious visits because the clinical talent is unable to correctly diagnose and treat the condition.

Lastly, cost of care comprises multiple sources including:
• Payment (possibly from several sources) for services rendered
• Insurance assignment (what the clinical entity agrees to accept from an insurance company whose insurance it accepts)
• Government reimbursement
• Tax write-offs
• The costs incurred by the clinical entity that delivers health care.

As previously mentioned, in this model, if one component or "leg" is removed the "stool" collapses.

If a patient has access to care and the means to pay, but the quality of care is sub-standard or even harmful resulting in further suffering or even death, the health care system has failed the patient.

If the patient has access to quality care, but is unable to afford it either because he/she lacks insurance or cannot pay out-of-pocket costs, then the system has once again failed the patient. It is important to note that because of the Federal Emergency Medical Treatment and Labor Act (EMTALA) an Emergency Department (ED) must evaluate a patient and if emergent treatment is required, the patient must be stabilized. However, the patient will then receive a bill for the full fees for service – not the discounted rates health care providers negotiate with insurance companies.

In the third scenario, if the patient lacks access to care because of distance, disability, or other transportation issues (this excludes ambulance), the system has again failed the patient because he/she cannot get to a place where he/she can get the necessary care (e.g., daily physical therapy, etc.).

This example of the interrelationship among access, quality, and cost underscores the fragile ecology of the health care system in the United States today and is call to action to payers, providers, and regulators to provide oversight and governance as well as transparency. Health care vendors affect and are affected by the interrelationship among access, quality, and cost. Prohibitive costs for payers and providers affect sales of vendor products and services or force vendors to dilute their offerings. Health care vendors can positively affect quality of health care that is provided by offering products to enable provider organizations to proactively oversee, trouble shoot, and remediate quality issues. They can affect cost as well by providing products and services that are not only compliant in the present but will continue to remain compliant as the policies change because there are both hard and soft dollar savings to providers.

Managing the Information, Not the Cost:

An example of what can sometimes be a paradoxical health care system interrelationship is that between the process of providing care and the actual efficient provisioning of quality care.

While most health care providers comply with the federal mandate to adopt electronic medical records by 2014, many are still struggling with manual processes, information silos, and issues of interconnectivity among disparate providers and payers. There is also the paradox of hospitals steadily closing their doors over the last 25 plus years and Emergency Departments (EDs) that continue to be crammed full of patients who must sometimes wait inordinate amounts of time to be triaged, treated, and admitted/discharged.

One barrier to prompt triage and treatment in an emergency department is process inefficiencies (or lack of qualified medical personnel). Take the example of a of a dying patient struggling to produce proof of insurance to the emergency department registrar – the gatekeeper to diagnosis and treatment – before collapsing dead on the hospital floor.

But the process goes beyond just proof of insurance and performing the intake. It extends to the ability to:
• Access existing electronic medical history
• Triage the patient, order labs, imaging, and/or other tests
• Compile results
• Make a correct diagnosis
• Correctly treat the patient
• Comply with federal/state regulations.

A breakdown in any of these steps in the process can negatively affect the health and well-being of the patient – and the reputation of the hospital.

Some providers have taken a hard look at their systems and streamlined and automated them as well as created more efficient workflow processes. These providers have been effective in both delivering prompt care and reducing both costs and patient grievances/complaints. One health care executive indicates that he advises his staff to manage the information rather than the money because the longer it takes to register a patient, triage that patient, refer him/her to a program, get him/her into the correct program, ensure the patient remains until treated, bill the correct payer, and get paid, the more money is lost.

The provisioning of satisfactory health care is related to both provider and payer process and workflow. By removing inefficiencies and waste and moving toward streamlining and standardizing processes and automating workflows health care provider executives will likely provide patients with better access to quality medical care that at reduced cost for their organizations.

The Letter of the Law:

Another tenuous interrelationship is among the law (specifically Health Insurance Portability and Accountability Act of 1996 (HIPAA)) and the enforcement thereof, technology (i.e., treatment of electronic medical records), and how provider organizations protect private health information (PHI) – or don't. Two incidents that made national news are discussed in the New York Times article by Milt Freudenheim, Robert Pear (2006) entitled "Health Hazard: Computers Spilling Your History." The two incidents:
(1) Former President Bill Clinton, who was admitted to New York-Presbyterian Hospital for heart surgery. (Hackers including hospital staff were trying to access President Clinton's electronic medical records and his patient care plan.)
(2) Nixzmary Brown, the seven-year-old who was beaten to death by her stepfather. (According to the Times, the New York City public hospital system reported that "dozens" of employees at one of its Brooklyn medical centers had illegally accessed Nixzmary's electronic medical records.)

These two incidents, and there have certainly been many more, illustrate the tenuous interrelationship among a law that was passed, in part, to protect private health information, abuses that have been perpetrated, and the responsibility of health care organizations to their patients right to privacy and confidentiality.

Progress has been and is being made with:
• More stringent self-policing and punitive measures
• Use of more sophisticated applications to track staff member log-ons and only permitting staff who have direct contact with a patient to see that patient's electronic medical records
• Hiring, or promoting from within, IT compliance officers who understand the business, the law, and technology to ensure that patient information is handled in a compliant manner within health care facilities' walls as well as preventing outside breaches.

Compliance with privacy laws is dependent upon being able to enforce those laws, and having processes and technology in place that detect, identify, report, and prevent abuses. Technology is far ahead of the laws and policies that govern it. Moreover, the creation of law does not always go hand-in-hand with its enforcement. Health care technology vendors must work with their provider customers to better understand their environments and to craft products that enable health care providers to safeguard PHI and remain compliant. Health care regulators must continuously address how to regulate new and emerging technologies as well as how to enforce them.

Summary

The above are just three examples of the myriad interrelationships among the aforementioned health care components. It is clear that no one element stands alone and that all are interconnected, many in innumerable ways. It also underscores the fact that health care executives, whether payers, providers, vendors, etc. must understand these interrelationships and how they can help/harm their respective organizations - and patients.

RFG POV: Health care executives are challenged to develop and deliver solutions even though the state of the industry is in flux and the risk of missing the mark can be high. Therefore, executives should continuously ferret out the changing requirements, understand applicability, and find ways to strengthen existing, and forge new, interrelationships and solution offerings. To minimize risks executives need to create flexible processes and agile, modular solutions that can be easily adjusted to meet the latest marketplace demands.